51
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Schädle P, Tschritter O, Kellerer M. Metformin Associated Lactic Acidosis in Clinical Practice - A Case Series. Exp Clin Endocrinol Diabetes 2020; 129:842-847. [PMID: 32403137 DOI: 10.1055/a-1149-9030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIMS The aim of this case report is to specify the frequency and mortality of Metformin-Associated Lactic Acidosis (MALA) in emergency medicine, as the diagnosis seems to occur more often than estimated. METHODS To identify the subjects, we developed screening criteria for MALA. We measured the serum metformin concentration to confirm the diagnosis in all patients fulfilling these criteria. Retrospectively the patients were grouped according to individual risk (according to a defined risk score) and the application of renal replacement therapy. RESULTS From 2013 until 2018 we were able to identify 11 MALA patients revealing a frequency of 1:4,000 emergency patients. Six patients survived and five died in the follow-up. All three patients in the high-risk group died although all of them received renal replacement therapy. In the low-risk group (three patients, one with renal replacement therapy), all patients survived, while in the intermediate-risk group (five patients, one with renal replacement therapy) three patients survived and two died. Additional severe comorbidities also contributed to mortality. CONCLUSIONS Every patient matching the screening criteria of acute renal failure, lactic acidosis and continued intake of metformin can be considered a potential MALA case. A risk score assessment which includes severe comorbidities may help to identify high-risk individuals and should be evaluated in larger studies.To prevent MALA, patients should be trained to immediately interrupt their own metformin use when showing signs of volume depletion. Physicians should be aware of the additional risk factors such as co-medication with diuretics, ACE (angiotensin converting enzyme) ACE inhibitors and NSAIDs (non steroidal anti inflammatory drugs).
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Affiliation(s)
- Philipp Schädle
- Centre of Internal Medicine I, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Stuttgart, Germany
| | - Otto Tschritter
- Centre of Internal Medicine I, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Stuttgart, Germany.,Emergency Department, Zollernalb Klinikum gGmbH, Balingen, Germany
| | - Monika Kellerer
- Centre of Internal Medicine I, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Stuttgart, Germany
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Gor D, Gerber BS, Walton SM, Lee TA, Nutescu EA, Touchette DR. Antidiabetic drug use trends in patients with type 2 diabetes mellitus and chronic kidney disease: A cross-sectional analysis of the National Health and Nutrition Examination Survey. J Diabetes 2020; 12:385-395. [PMID: 31652390 DOI: 10.1111/1753-0407.13003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/25/2019] [Accepted: 10/13/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is little information on medication use, trends across time, and the impact of guidelines on appropriate use of antidiabetic drugs in participants with type 2 diabetes mellitus (T2DM) with chronic kidney disease (CKD). METHODS A cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) from 2005-2016 was carried out for participants with T2DM with and without CKD. Multivariate survey-weighted regression models were used to evaluate trends in antidiabetic drug use across the time periods and CKD severity. Guideline-discordant use of metformin and glyburide were assessed among those with glomerular filtration rate and serum creatinine-based contraindications. RESULTS Out of 3237 study participants with T2DM, 35.9% had CKD. Comparing 2013-2016 with 2005-2008, use of metformin (non-CKD: 69% vs 83.8%, CKD: 58.6% vs 68.2%) increased, whereas the use of sulfonylureas (non-CKD: 46.3% vs 27.2%, CKD: 54.7% vs 36.6%) and thiazolidinediones (non-CKD: 29.3% vs 3.9%, CKD: 24.6% vs 5.5%) decreased. In combined NHANES cycles and across stages of CKD severity, metformin use decreased (non-CKD, stage 1/2, stage 3, stage 4/5: 78.4%, 69.5%, 54.6%, 4.9%, respectively; P < .01), and insulin use increased (18.5%, 26.8%, 25%, 52.8%, respectively; P < .01) from non-CKD to progressed CKD. Guideline-discordant use of metformin and glyburide was observed in 8.3% and 2.8% of the participants, respectively, in 2013-2016. CONCLUSIONS Use of particular antidiabetic medications in patients with CKD changed noticeably over the years, most in accordance with guidelines and regulatory decisions. Gaps in quality of care still exist, which warrants increasing awareness and implementing programs to mitigate inappropriate use.
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Affiliation(s)
- Deval Gor
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Ben S Gerber
- Division of Academic Internal Medicine and Geriatrics, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Surrey M Walton
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Edith A Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
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53
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Kwon S, Kim YC, Park JY, Lee J, An JN, Kim CT, Oh S, Park S, Kim DK, Oh YK, Kim YS, Lim CS, Lee JP. The Long-term Effects of Metformin on Patients With Type 2 Diabetic Kidney Disease. Diabetes Care 2020; 43:948-955. [PMID: 32132005 DOI: 10.2337/dc19-0936] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 02/09/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Metformin is the first pharmacological option for treating type 2 diabetes. However, the use of this drug is not recommended in individuals with impaired kidney function because of the perceived risk of lactic acidosis. We aimed to assess the efficacy and safety of metformin in patients with type 2 diabetic kidney disease (DKD). RESEARCH DESIGN AND METHODS We conducted a retrospective observational cohort study of 10,426 patients with type 2 DKD from two tertiary hospitals. The primary outcomes were all-cause mortality and end-stage renal disease (ESRD) progression. The secondary outcome was metformin-associated lactic acidosis. Taking into account the possibility that patients with less severe disease were prescribed metformin, propensity score matching (PSM) was conducted. RESULTS All-cause mortality and incident ESRD were lower in the metformin group according to the multivariate Cox analysis. Because the two groups had significantly different baseline characteristics, PSM was performed. After matching, metformin usage was still associated with lower all-cause mortality (adjusted hazard ratio [aHR] 0.65; 95% CI 0.57-0.73; P < 0.001) and ESRD progression (aHR 0.67; 95% CI 0.58-0.77; P < 0.001). Only one event of metformin-associated lactic acidosis was recorded. In both the original and PSM groups, metformin usage did not increase the risk of lactic acidosis events from all causes (aHR 0.92; 95% CI 0.668-1.276; P = 0.629). CONCLUSIONS In the present retrospective study, metformin usage in advanced chronic kidney disease (CKD) patients, especially those with CKD 3B, decreased the risk of all-cause mortality and incident ESRD. Additionally, metformin did not increase the risk of lactic acidosis. However, considering the remaining biases even after PSM, further randomized controlled trials are needed to change real-world practice.
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Affiliation(s)
- Soie Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Yoon Park
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jeonghwan Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jung Nam An
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Korea
| | - Clara Tammy Kim
- Institute of Life and Death Studies, Hallym University, Chuncheon, Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seokwoo Park
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea .,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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54
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Yu Q, Zhu JJ, Liu WX. Effect of continuous use of metformin on kidney function in diabetes patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. BMC Cardiovasc Disord 2020; 20:187. [PMID: 32316910 PMCID: PMC7175536 DOI: 10.1186/s12872-020-01474-5] [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] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/12/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Diabetes patients presenting with ST-segment elevation myocardial infarction (STEMI) scheduled for primary percutaneous coronary intervention (PCI) have an increased risk of contrast induced-acute kidney injury (CI-AKI). The effects of continuous use of metformin on kidney function are still controversial in patients submitted to primary PCI. This study aimed to assess continuous metformin therapy on kidney function in diabetic patients undergoing coronary intervention. METHODS Two hundred eighty-four patients with metformin-treated diabetes, who underwent coronary intervention within 24 h for STEMI, were enrolled in the retrospective study. All the patients had estimated glomerular filtration rate (eGFR) of > 30 mL/min/1.73 m2. According to the physicians' decisions after admission, 119 patients continued metformin treatment after primary PCI, while 165 patients discontinued it > 48 h after the procedure. Serum creatinine was collected at admission and within 48 h post primary PCI to evaluate the incidence of CI-AKI. We performed a multiple logistic regression analysis to examine the determinants of CI-AKI. RESULTS No statistical difference in CI-AKI incidence between the continuous and the discontinuous metformin group (12.6%vs10.3%, p = 0.545). Multivariable logistic regression analysis indicated eGFR ≤60 ml/min/1.73 m2[p = 0.025, OR: 3.131; 95% CI (1.156-8.482)] and contrast volume [p = 0.002, OR: 1.010; 95% CI (1.004-1.016)] were predictive factors of CI-AKI. Metformin therapy was irrelevant to CI-AKI [p = 0.365, OR: 0.698; 95% CI (0.320-1.521)]. No case of lactic acidosis was found in this study. Besides, the study supported discontinuation of metformin was not beneficial for patients' blood glucose control after admission. CONCLUSIONS The study indicated that the metformin continuation after primary PCI for STEMI in diabetic patients with eGFR > 30 ml/min / 1.73 m2 did not increase the risk of CI-AKI.
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Affiliation(s)
- Qi Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
| | - Jia-Jia Zhu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
| | - Wen-Xian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
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The Association of Premorbid Metformin Exposure With Mortality and Organ Dysfunction in Sepsis: A Systematic Review and Meta-Analysis. Crit Care Explor 2020; 1:e0009. [PMID: 32166255 PMCID: PMC7063877 DOI: 10.1097/cce.0000000000000009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. To examine the association between premorbid metformin exposure and mortality, hyperlactatemia, and organ dysfunction in sepsis.
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56
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Zhang K, Yang W, Dai H, Deng Z. Cardiovascular risk following metformin treatment in patients with type 2 diabetes mellitus: Results from meta-analysis. Diabetes Res Clin Pract 2020; 160:108001. [PMID: 31904444 DOI: 10.1016/j.diabres.2020.108001] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/17/2019] [Accepted: 12/31/2019] [Indexed: 12/16/2022]
Abstract
AIM Pharmacologic therapy for T2DM has proven benefits in terms of reducing elevated blood glucose levels and reducing microvascular complications. However, the impact of metformin on adverse cardiovascular outcomes and cardiovascular mortality is less clear. We carried out this meta-analysis on all published studies to estimate the overall cardiovascular risk following metformin treatment in patients with T2DM. METHODS We searched the PubMed, Embase and CNKI (China National Knowledge Infrastructure) databases for all articles. The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the cardiovascular risk following metformin treatment in patients with T2DM. The statistical heterogeneity among studies was assessed with the Q-test and I2 statistics. RESULTS We collected 16 studies including 25 comparisons with 1,160,254 patients of type 2 diabetes mellitus and 701,843 patients of T2DM following metformin treatment. Our results found statistical evidence of significantly decreased cardiovascular risk to be associated with following treatment with metformin in patients with type 2 diabetes mellitus (OR = 0.57, 95% CI = 0.48-0.68) (shown in Table 1 and Fig. 2), both with the mortality (OR = 0.44, 95% CI = 0.34-0.57) and incidence (OR = 0.73, 95% CI = 0.59-0.90). CONCLUSIONS Our meta-analysis indicated that following metformin treatment in patients with T2DM was associated with decreased cardiovascular risk, both with the mortality and incidence. However, the heterogeneity among studies may potentially affect the final results.
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Affiliation(s)
- Kui Zhang
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China
| | - Wenxing Yang
- Department of Physiology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China
| | - Hao Dai
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China
| | - Zhenhua Deng
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan 610041, People's Republic of China.
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57
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Akhter MS, Uppal P. Toxicity of Metformin and Hypoglycemic Therapies. Adv Chronic Kidney Dis 2020; 27:18-30. [PMID: 32146997 DOI: 10.1053/j.ackd.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/01/2019] [Indexed: 12/15/2022]
Abstract
Metformin along with other antidiabetic medications provide benefit to patients in the treatment of type 2 diabetes mellitus, but caution is advised in certain scenarios to avoid toxicity in kidney disease. Renal dosing, monitoring of kidney function, and evaluating the risk of developing serious side effects are warranted with some agents. The available literature with regard to incidence of adverse events and toxicity of hypoglycemic therapies is reviewed.
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58
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Schernthaner G, Schernthaner GH. The right place for metformin today. Diabetes Res Clin Pract 2020; 159:107946. [PMID: 31778746 DOI: 10.1016/j.diabres.2019.107946] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 02/06/2023]
Abstract
Metformin is the most widely used glucose lowering drug worldwide in the treatment of patients with type 2 diabetes, since we have experience with this drug for more than 60 years about the efficacy and safety. Metformin is very effective in HbA1c lowering associated with some weight loss, but does not increase risk for hypoglycemia. At the moment all guidelines in the world recommend to use metformin in monotherapy in patients with newly diagnosed diabetes or in combination with other antidiabetic drugs with documented CV (and renal) benefit in cardiovascular outcome trials (CVOT). Although a randomized placebo controlled CVOT with metformin is lacking, many observational studies in patients with coronary heart disease, heart failure and chronic kidney disease have demonstrated consistent beneficial effects. A recent metanalysis of 26 observational studies including 815 839 patients showed that metformin use was associated with a significantly lower rate of all-cause mortality (HR: 0.74; 95% CI: 0.68-0.81). Whether this very consistent reduction of all-cause mortality is related to the incidence/outcome of several cancers has still to be investigated. In the future early combination therapy of metformin e.g. with SGLT-2 inhibitors should be more often used.
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Affiliation(s)
- Guntram Schernthaner
- Rudolfstiftung Hospital & Medical University of Vienna, Department of Medicine II, Vienna, Austria; Medical University of Vienna, Department of Medicine II, Vienna, Austria
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59
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Use of Empagliflozin in Recipients of Kidney Transplant: A Report of 8 Cases. Transplant Proc 2019; 51:3275-3280. [PMID: 31732204 DOI: 10.1016/j.transproceed.2019.05.023] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/03/2019] [Accepted: 05/13/2019] [Indexed: 02/06/2023]
Abstract
Transplant teams face increasing challenges to manage diabetes following kidney transplantation. There is an increasing number of diabetics undergoing transplantation and there is an increased incidence of posttransplant diabetes mellitus (PTDM) due to a higher prevalence of obesity, increased use of steroids and calcineurin inhibitors, and the acceptance of older patients as potential candidates. The options for treating diabetes in the general population are expanding. Sodium-glucose cotransporter 2 (SGLT-2) inhibitors is one of the new modalities of treatment. We report the cases of 8 patients who underwent kidney transplantation and were treated with the SGLT-2 inhibitor empagliflozin for their pre-existing diabetes or for the development of PTDM. They were followed for an average of 12 months. The average age of the patients was 42.5 years. All 8 patients were taking tacrolimus, mycophenolate, and prednisolone. Although creatinine increased slightly (from 88.5 mmol/L to 99.5 mmol/L) in the month after starting empagliflozin, it stabilized after that. Hemoglobin A1c decreased on average 0.85 g/dL. Urine protein decreased by 0.6 g per day and weight decreased on average 2.4 kg throughout the year. One patient discontinued the medication due to recurrent urinary tract infections.
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60
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Rhee JJ, Han J, Montez-Rath ME, Kim SH, Cullen MR, Stafford RS, Winkelmayer WC, Chertow GM. Antidiabetic medication use in patients with type 2 diabetes and chronic kidney disease. J Diabetes Complications 2019; 33:107423. [PMID: 31537413 PMCID: PMC6823164 DOI: 10.1016/j.jdiacomp.2019.107423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/19/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
Abstract
AIMS To quantify patterns of conventional and newer antidiabetic medication use in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). METHODS We used data from a large claims and integrated dataset that includes employed and commercially insured patients in the US to select patients who had T2DM and CKD with information on laboratory values and prescriptions for antidiabetic medications from January 1, 2014 to January 1, 2015. We stratified the analyses by sociodemographic variables. RESULTS In a cohort of 38,577 patients with T2DM and CKD, we found wide variation in the treatment of T2DM by CKD stage as well as by several sociodemographic factors. Although metformin was the most commonly prescribed medication, only about half of patients in the cohort and fewer than two-thirds of patients with early stage CKD were prescribed metformin. Approximately 10.6% of patients with CKD stage 4 and 2.1% of the patients with CKD stage 5 were prescribed metformin. Sulfonylureas with active metabolites that accumulate with impaired kidney function were prescribed in more than one-third of patients with CKD stages 3b, 4, and 5. Only 3.4% and 12.3% of patients were prescribed GLP-1 and DPP-4 respectively. CONCLUSIONS Prescriptions for metformin were lower than expected among patients with mild to moderate CKD. Prescriptions for newer antidiabetic medications with known safety and efficacy across the spectrum of CKD remained low. Prescriptions for agents contraindicated in advanced CKD continued to be written in a sizeable fraction of patients.
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Affiliation(s)
- Jinnie J Rhee
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States; Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States.
| | - Jialin Han
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States
| | - Sun H Kim
- Division of Endocrinology, Gerontology, and Metabolism, Stanford University School of Medicine, Stanford, CA, United States; Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Mark R Cullen
- Division of Primary Care and Population health, Stanford University School of Medicine, Stanford, CA, United States
| | - Randall S Stafford
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA, United States; Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
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Salvatore T, Pafundi PC, Marfella R, Sardu C, Rinaldi L, Monaco L, Ricozzi C, Imbriani S, Nevola R, Adinolfi LE, Sasso FC. Metformin lactic acidosis: Should we still be afraid? Diabetes Res Clin Pract 2019; 157:107879. [PMID: 31618624 DOI: 10.1016/j.diabres.2019.107879] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/27/2019] [Accepted: 10/11/2019] [Indexed: 12/11/2022]
Abstract
Metformin, the first choice drug for type 2 diabetes treatment in all stages of therapy, and one of the most widely prescribed anti-hyperglycemic agents worldwide, represents a rare example of an old drug which continues to display new beneficial effects in various fields. However, lactic acidosis (LA) persists as a serious adverse effect. LA incidence is low and is not necessarily determined by the administration of metformin. Unfortunately, the concern for this complication has negatively affected the drug use, particularly in chronic kidney disease, which may impair drug excretion, and in congestive heart failure and chronic liver disease, which may promote lactate accumulation. This review describes how not only these historical contraindications have been considerably scaled back, though rather a recent large body of evidence supports a protective effect of biguanide on kidney, heart and liver and, maybe, against lactic acidosis itself. It is worthy to slow down both contraindications and precautions to metformin use, not to deprive a significant number of diabetic patients, as those with kidney, heart and liver comorbidities, from its potential benefits, and not to hamper in the near future the putative advantages in a wide spectrum of conditions outside of diabetes.
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Affiliation(s)
- Teresa Salvatore
- Unit of Internal Medicine, Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Pia Clara Pafundi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Lucio Monaco
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Carmen Ricozzi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Simona Imbriani
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Riccardo Nevola
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Luigi Elio Adinolfi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Piazza Miraglia, 2, 80138 Naples, Italy.
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Metformin use and risk of gastric adenocarcinoma in a Swedish population-based cohort study. Br J Cancer 2019; 121:877-882. [PMID: 31591459 PMCID: PMC6889304 DOI: 10.1038/s41416-019-0598-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background Whether or not the use of metformin decreases the risk of gastric adenocarcinoma is unclear. Methods This was a population-based cohort study in 2005–2015. Associations between metformin use and gastric non-cardia and cardia adenocarcinomas were examined within two cohorts; a diabetes cohort of participants using anti-diabetes medications, and a matched cohort of common-medication users, where metformin non-users were frequency matched (10:1) with metformin users for sex and age. Multivariable Cox proportional hazard regression analyses provided hazard ratios (HR) and 95% confidence intervals (CI), adjusting for sex, age, calendar year, comorbidity, Helicobacter pylori eradication treatment, use of non-steroidal anti-inflammatory drugs or aspirin and use of statins. Results During the follow-up for a median of 5.8 years, 892 (0.1%) participants in the diabetes cohort and 6395 (0.1%) participants in the matched cohort of common-medication users developed gastric adenocarcinoma. Metformin users had no significantly decreased risk of gastric non-cardia adenocarcinoma (diabetes cohort: HR 0.93, 95% CI 0.78–1.12; matched cohort: HR 1.30, 95% CI 1.18–1.42) or cardia adenocarcinoma (diabetes cohort: HR 1.49, 95% CI 1.09–2.02; matched cohort: HR 1.58, 95% CI 1.38–1.81) compared with non-users in both cohorts. Conclusions This cohort study with <10 years of follow-up suggests metformin use may not prevent gastric adenocarcinoma.
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Roumie CL, Chipman J, Min JY, Hackstadt AJ, Hung AM, Greevy RA, Grijalva CG, Elasy T, Griffin MR. Association of Treatment With Metformin vs Sulfonylurea With Major Adverse Cardiovascular Events Among Patients With Diabetes and Reduced Kidney Function. JAMA 2019; 322:1167-1177. [PMID: 31536102 PMCID: PMC6753652 DOI: 10.1001/jama.2019.13206] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/09/2019] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Before 2016, safety concerns limited metformin use in patients with kidney disease; however, the effectiveness of metformin on clinical outcomes in patients with reduced kidney function remains unknown. OBJECTIVE To compare major adverse cardiovascular events (MACE) among patients with diabetes and reduced kidney function who continued treatment with metformin or a sulfonylurea. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of US veterans receiving care within the national Veterans Health Administration, with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2001 through 2016. There were 174 882 persistent new users of metformin and sulfonylureas who reached a reduced kidney function threshold (estimated glomerular filtration rate <60 mL/min/1.73 m2 or creatinine ≥1.4 mg/dL for women or ≥1.5 mg/dL for men). Patients were followed up from reduced kidney function threshold until MACE, treatment change, loss to follow-up, death, or study end (December 2016). EXPOSURES New users of metformin or sulfonylurea monotherapy who continued treatment with their glucose-lowering medication after reaching reduced kidney function. MAIN OUTCOMES AND MEASURES MACE included hospitalization for acute myocardial infarction, stroke, transient ischemic attack, or cardiovascular death. The analyses used propensity score weighting to compare the cause-specific hazard of MACE between treatments and estimate cumulative risk accounting for the competing risks of changing therapy or noncardiovascular death. RESULTS There were 67 749 metformin and 28 976 sulfonylurea persistent monotherapy users; the weighted cohort included 24 679 metformin and 24 799 sulfonylurea users (median age, 70 years [interquartile range {IQR}, 62.8-77.8]; 48 497 men [98%]; and 40 476 white individuals [82%], with median estimated glomerular filtration rate of 55.8 mL/min/1.73 m2 [IQR, 51.6-58.2] and hemoglobin A1c level of 6.6% [IQR, 6.1%-7.2%] at cohort entry). During follow-up (median, 1.0 year for metformin vs 1.2 years for sulfonylurea), there were 1048 MACE outcomes (23.0 per 1000 person-years) among metformin users and 1394 events (29.2 per 1000 person-years) among sulfonylurea users. The cause-specific adjusted hazard ratio of MACE for metformin was 0.80 (95% CI, 0.75-0.86) compared with sulfonylureas, yielding an adjusted rate difference of 5.8 (95% CI, 4.1-7.3) fewer events per 1000 person-years of metformin use compared with sulfonylurea use. CONCLUSIONS AND RELEVANCE Among patients with diabetes and reduced kidney function persisting with monotherapy, treatment with metformin, compared with a sulfonylurea, was associated with a lower risk of MACE.
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Affiliation(s)
- Christianne L. Roumie
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center, Nashville
- Department of Medicine, Vanderbilt University Medical Center, Nashville
| | - Jonathan Chipman
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jea Young Min
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center, Nashville
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amber J. Hackstadt
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Adriana M. Hung
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center, Nashville
- Department of Medicine, Vanderbilt University Medical Center, Nashville
| | - Robert A. Greevy
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Carlos G. Grijalva
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center, Nashville
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tom Elasy
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center, Nashville
- Department of Medicine, Vanderbilt University Medical Center, Nashville
| | - Marie R. Griffin
- Veteran Administration Tennessee Valley VA Health Care System Geriatric Research Education Clinical Center, Nashville
- Department of Medicine, Vanderbilt University Medical Center, Nashville
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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Bergmark BA, Bhatt DL, McGuire DK, Cahn A, Mosenzon O, Steg PG, Im K, Kanevsky E, Gurmu Y, Raz I, Braunwald E, Scirica BM. Metformin Use and Clinical Outcomes Among Patients With Diabetes Mellitus With or Without Heart Failure or Kidney Dysfunction. Circulation 2019; 140:1004-1014. [DOI: 10.1161/circulationaha.119.040144] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Metformin is first-line therapy for type 2 diabetes mellitus, although its effects on the cardiovascular system are unproved.
Methods:
In this post hoc analysis, patients in SAVOR-TIMI 53 (Saxagliptin and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus) with baseline biomarker samples (n=12 156) were classified as ever versus never taking metformin during the trial period. Associations between metformin exposure and outcomes were estimated with inverse probability of treatment weighting Cox modeling for the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke, as well as cardiovascular death and all-cause mortality, with biomarkers included as covariates. Additional sensitivity analyses included propensity score matching and Cox multivariable models.
Results:
Of the 12 156 patients with baseline biomarker samples, 8971 (74%) had metformin exposure, 1611 (13%) had prior heart failure, and 1332 (11%) had at least moderate chronic kidney disease (estimated glomerular filtration rate ≤45 mL·min
−1
·1.73 m
−2
). Metformin use was associated with no difference in risk for the composite end point (hazard ratio for inverse probability of treatment weighting, 0.92 [95% CI, 0.76–1.11]) but lower risk of all-cause mortality (hazard ratio for inverse probability of treatment weighting, 0.75 [95% CI, 0.59–0.95]). There was no significant relationship between metformin use and these end points in patients with prior heart failure or moderate to severe chronic kidney disease.
Conclusions:
In a cohort of 12 156 patients with type 2 diabetes mellitus and high cardiovascular risk, metformin use was associated with lower rates of all-cause mortality, including after adjustment for clinical variables and biomarkers, but not lower rates of the composite end point of cardiovascular death, myocardial infarction, or ischemic stroke. This association was most apparent in patients without prior heart failure or moderate to severe chronic kidney disease.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01107886.
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Affiliation(s)
- Brian A. Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Avivit Cahn
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Ofri Mosenzon
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Ph. Gabriel Steg
- FACT (French Alliance for Cardiovascular Clinical Trials), Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation, Remodelling), Université de Paris, Sorbonne Paris-Cité, France (P.G.S.)
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
- INSERM U-1148, Paris, France (P.G.S.)
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, UK (P.G.S.)
| | - KyungAh Im
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Estella Kanevsky
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Yared Gurmu
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Itamar Raz
- Diabetes Unit, Division of Internal Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, The Faculty of Medicine, Israel (A.C., O.M., I.R.)
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Benjamin M. Scirica
- Thrombolysis in Myocardial Infarction (TIMI) Study Group (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Cardiovascular Division, Heart and Vascular Center (B.A.B., D.L.B., K.I., E.K., Y.G., E.B., B.M.S.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Metformin - Postmortem fatal and non-fatal reference concentrations in femoral blood and risk factors associated with fatal intoxications. Forensic Sci Int 2019; 303:109935. [PMID: 31491622 DOI: 10.1016/j.forsciint.2019.109935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/05/2019] [Accepted: 08/21/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND & OBJECTIVES To improve the interpretation of fatal intoxications by establishing fatal and non-fatal reference concentrations of metformin in postmortem femoral blood and to further evaluate risk factors associated with fatal metformin intoxication. METHODS All forensic autopsies in Sweden where metformin was detected in femoral blood 2011-2016 were identified in the National Board of Forensic Medicine databases (NFMD). The cases were classified as single substance intoxications, A (n = 22), multiple substance intoxications, B (N = 7) and postmortem controls, C (N = 13). The control group consisted of cases where metformin was detected, but the cause of death excluded the incapacitation by metformin or other substances. Strict inclusion criteria were used, and all postmortem cases were assessed by two independent reviewers. All other cases where the inclusion criteria of groups A-C where not met formed group O (N = 78). The forensic findings logged in the NFMD where linked to national registers whereby information on comorbidities, dispensed drugs and clinical data could be obtained. RESULTS The mean age was 66 ± 10 years in the total study population and did not differ between the groups. The proportion of men was 64% in group A, 71% in B, 77% in C and 74% in group O. The median values of metformin in group A (48.5 μg/g; range 13.0-210 μg/g) and B (21.0 μg/g; range 4.40-95.0 μg/g) were significantly (p < 0.001 and p = 0.015 respectively) higher than those of the control group C (2.30 μg/g ; range 0.70-21.0 μg/g). The median concentration of metformin in group A and B was also significantly higher than in group O (4.60 μg/g; range 0.64-54.0 μg/g) (p < 0.001 and p = 0.040 respectively). The results suggest that intoxication with metformin as a cause of death should be considered when the postmortem femoral blood level exceeds about 10 μg/g, although higher levels may be seen in postmortem in cases without incapacitation. The metformin intoxication was confirmed to be intentional in 23% (n = 5) of the single intoxications. Underlying factors identified as important for the remaining fatal metformin intoxications included living alone, any contraindication for the use of metformin, known alcohol abuse and a history of stroke or cardiovascular disease. CONCLUSIONS The reported post mortem femoral blood concentrations of metformin can hopefully contribute to a better interpretation of results in suspected poisonings and obscure cases. Living in a single household, history of cardiovascular disease and contraindications, predominantly alcohol abuse, were associated with fatal metformin intoxication.
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66
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Sorohan BM, Ismail G, Andronesi A, Micu G, Obrișcă B, Jurubiță R, Sinescu I, Baston C. A single-arm pilot study of metformin in patients with autosomal dominant polycystic kidney disease. BMC Nephrol 2019; 20:276. [PMID: 31337351 PMCID: PMC6651959 DOI: 10.1186/s12882-019-1463-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Metformin has shown promising results regarding cystogenesis inhibition in preclinical studies with autosomal dominant polycystic kidney disease (ADPKD) models. We designed a prospective, preliminary, single-arm study to evaluate the tolerability, safety and the effect of Metformin on kidney function and body mass index (BMI) in Romanian patients with ADPKD. Methods We enrolled 34 adult patients with ADPKD, chronic kidney disease (CKD) stages 1–5 not on dialysis and without diabetes mellitus. The primary endpoint was to assess the tolerability and safety of Metformin. The secondary endpoints evaluated changes in estimated glomerular filtration rate (eGFR), body mass index (BMI) and renal replacement therapy (RRT) necessity. Patients received an initial dose of Metformin of 500 mg/day within the first month that was increased to 1000 mg/day thereafter according to tolerability. Change in eGFR and BMI was expressed as mean difference with the corresponding 95% confidence intervals and as a percentage. For the primary endpoint, we included all 34 enrolled patients. To assess the secondary endpoint, intention-to-treat (ITT) and per-protocol (PP) analysis was performed. Results Sixteen patients out of 34 completed the follow-up period at 24 months. Eighteen patients developed adverse events and 63.6% of these events were gastrointestinal related. Nausea was the most common adverse event (17.6%). Two patients (5.8%) permanently discontinued medication due to adverse events. We recorded no case of hypoglycemia, lactic acidosis or death. Mean eGFR changed by − 1.57 ml/min/1.73m2 (95%CI:-22.28 to 19.14, P = 0.87) in ITT and by − 4.57 ml/min/1.73m2 (95%CI:-28.03 to 18.89, P = 0.69) in PP population. Mean BMI change was − 1.10 kg/m2 (95%CI:-3.22 to 1.02, P = 0.30) in ITT population and − 0.80 kg/m2 (95%CI:-3.27 to 1.67, P = 0.51) in PP analysis. Three patients (8.8%) needed RRT. Conclusions Metformin was well tolerated, had a good safety profile even in ADPKD patients with advanced CKD and it was not associated with change in eGFR or BMI across the follow-up period. Trial registration The study was retrospectively registered on https://www.isrctn.com (number ISRCTN 93749377); date registered: 02/25/2019.
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Affiliation(s)
- Bogdan Marian Sorohan
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Gener Ismail
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. .,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania.
| | - Andreea Andronesi
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Georgia Micu
- Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Bogdan Obrișcă
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Roxana Jurubiță
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Ioanel Sinescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Cătălin Baston
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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67
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Fadini GP, Frison V, Simioni N, Lapolla A, Gatti A, Bossi AC, Del Buono A, Fornengo P, Gottardo L, Laudato M, Perseghin G, Bonora E, Avogaro A. Changes in the Prescription of Glucose-Lowering Medications in Patients With Type 2 Diabetes Mellitus After a Cardiovascular Event: A Call to Action From the DATAFILE Study. J Am Heart Assoc 2019; 8:e012244. [PMID: 31269877 PMCID: PMC6662129 DOI: 10.1161/jaha.119.012244] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Evidence accumulated that some glucose‐lowering medications protect against cardiovascular events (CVEs) in patients with type 2 diabetes mellitus (T2DM) and established cardiovascular disease. The present study evaluated if and how glucose‐lowering medication prescription pattern changes in T2DM after a CVE. Methods and Results DATAFILE (Diabetes Therapy After a Cardiovascular Event) was a retrospective multicenter study conducted at 12 diabetes mellitus specialist outpatient clinics in Italy. We identified T2DM patients with an incident CVE for whom a follow‐up visit was available after the event. We selected control T2DM patients without an incident CVE, who were matched with cases for age, sex, known diabetes mellitus duration, baseline hemoglobin A1c, kidney function, and follow‐up time. We extracted clinical variables and compared prescribed therapies at baseline and follow‐up. We included 563 patients with and 497 matched patients without an incident CVE. As expected, patients with a subsequent CVE had a higher baseline prevalence of ischemic heart disease. After a median of 9.5 months, in patients with versus those without a CVE, there was a significant increase in the prescription of beta‐blockers, loop diuretics, dual antiplatelet therapy, and, among glucose‐lowering medications, a significant decrease in metformin. Hemoglobin A1c marginally declined only in the control group, whereas low‐density lipoprotein cholesterol decreased only in patients with CVE. Conclusions This study highlights that occurrence of a CVE in T2DM patients did not prime the prescription of glucose‐lowering medications provided with cardiovascular protective effects, even though glucose control remained poor. These data emphasize the need to optimize the therapeutic regimen of T2DM patients with established cardiovascular disease, according to updated guidelines.
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Affiliation(s)
| | - Vera Frison
- 2 Diabetology Service ULSS6 Cittadella Italy
| | | | | | - Adriano Gatti
- 4 Diabetology Service ASL Napoli 1 Centro Napoli Italy
| | | | | | - Paolo Fornengo
- 7 Department of Medicine Internal Medicine 3 University Hospital of Turin Italy
| | | | | | - Gianluca Perseghin
- 10 Department of Medicine and Rehabilitation Policlinico di Monza and University of Milan Bicocca Monza Italy
| | - Enzo Bonora
- 11 Division of Endocrinology, Diabetes and Metabolism University and Hospital Trust of Verona Verona Italy
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68
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Tanner C, Wang G, Liu N, Andrikopoulos S, Zajac JD, Ekinci EI. Metformin: time to review its role and safety in chronic kidney disease. Med J Aust 2019; 211:37-42. [PMID: 31187887 DOI: 10.5694/mja2.50239] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
■Metformin is recommended as first-line therapy for type 2 diabetes because of its safety, low cost and potential cardiovascular benefits. ■The use of metformin was previously restricted in people with chronic kidney disease (CKD) - a condition that commonly coexists with diabetes - due to concerns over drug accumulation and metformin-associated lactic acidosis. ■There are limited data from observational studies and small randomised controlled trials to suggest that metformin, independent of its antihyperglycaemic effects, may be associated with lower risk of myocardial infarction, stroke and all-cause mortality in people with type 2 diabetes and CKD. ■Research into the risk of metformin-associated lactic acidosis in CKD has previously been limited and conflicting, resulting in significant variation across international guidelines on the safe prescribing and dosing of metformin at different stages of renal impairment. ■Present-day large scale cohort studies now provide supporting evidence for the safe use of metformin in mild to moderate renal impairment (estimated glomerular filtration rate [eGFR] 30-60 mL/min/1.73m2 ). However, prescribing metformin in people with severe renal impairment (eGFR < 30 mL/min/1.73m2 ) remains a controversial issue. Due to observed increased risk of lactic acidosis and all-cause mortality in people with type 2 diabetes and severe renal impairment, it is generally recommended that metformin is discontinued if renal function falls below this level or during acute renal deterioration.
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Affiliation(s)
| | | | | | | | - Jeffrey D Zajac
- Austin Health, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Elif I Ekinci
- Austin Health, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
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69
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Rajasurya V, Anjum H, Surani S. Metformin Use and Metformin-associated Lactic Acidosis in Intensive Care Unit Patients with Diabetes. Cureus 2019; 11:e4739. [PMID: 31355098 PMCID: PMC6649884 DOI: 10.7759/cureus.4739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/23/2019] [Indexed: 01/09/2023] Open
Abstract
Metformin is a very potent anti-diabetic drug that has become the drug of choice for the treatment of type 2 diabetes. In addition to its glucose-lowering properties, it also reduces all-cause mortality through its anti-inflammatory and cardioprotective effects. Although metformin-associated lactic acidosis (MALA) is a very rare event, the mortality associated with it is close to 50%. As it is excreted through the kidney, MALA is frequently seen in patients on metformin with risk factors for developing acute kidney injury. Metformin increases the plasma lactate level in a concentration-dependent manner by inhibiting mitochondrial respiration, usually in the presence of a secondary event that disrupts lactate production or clearance. The incidence of acute kidney injury is very high in critically ill patients contributed by circulatory defects as well as contrast-induced nephropathy, the incidence of which is also high in this subset of the population. Because of this potential risk, metformin is frequently discontinued in diabetic patients admitted to the intensive care unit. Blood glucose variability and hypoglycemia, however, are both related to poor intensive care unit (ICU) outcomes and in order to prevent this in diabetic patients admitted to ICU, oral hypoglycemic agents are frequently switched to intravenous or subcutaneous insulin regimens, which allows for closer monitoring and better blood glucose control.
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Affiliation(s)
- Venkat Rajasurya
- Pulmonary Critical Care, Decatur Memorial Hospital, Decatur, USA
| | - Humayun Anjum
- Pulmonary Critical Care, Corpus Christi Medical Center, Corpus Christi, USA
| | - Salim Surani
- Internal Medicine, Texas A&M Health Science Center, Temple, USA
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70
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Charytan DM, Solomon SD, Ivanovich P, Remuzzi G, Cooper ME, McGill JB, Parving HH, Parfrey P, Singh AK, Burdmann EA, Levey AS, Eckardt KU, McMurray JJV, Weinrauch LA, Liu J, Claggett B, Lewis EF, Pfeffer MA. Metformin use and cardiovascular events in patients with type 2 diabetes and chronic kidney disease. Diabetes Obes Metab 2019; 21:1199-1208. [PMID: 30672083 DOI: 10.1111/dom.13642] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/07/2019] [Accepted: 01/19/2019] [Indexed: 01/29/2023]
Abstract
AIMS Metformin could have benefits on cardiovascular disease and kidney disease progression but is often withheld from individuals with diabetes and chronic kidney disease (CKD) because of a concern that it may increase the risk of lactic acidosis. MATERIALS AND METHODS All-cause mortality, cardiovascular death, cardiovascular events (death, hospitalization for heart failure, myocardial infarction, stroke or myocardial ischemia), end stage renal disease (ESRD) and the kidney disease composite (ESRD or death) were compared in metformin users and non-users with diabetes and CKD enrolled in the Trial to Reduce Cardiovascular Events with Aranesp (darbepoeitin-alfa) Therapy (TREAT) (NCT00093015). Outcomes were compared after propensity matching of users and non-users and in multivariable proportional hazards models. RESULTS There were 591 individuals who used metformin at baseline and 3447 non-users. Among propensity-matched users, the crude incidence rate for mortality, cardiovascular mortality, cardiovascular events and the combined endpoint was lower in metformin users than in non-users, but ESRD was marginally higher (4.0% vs 3.6%). Metformin use was independently associated with a reduced risk of all-cause mortality (HR, 0.49; 95% CI, 0.36-0.69), cardiovascular death (HR, 0.49; 95% CI, 0.32-0.74), the cardiovascular composite (HR, 0.67, 95% CI, 0.51-0.88) and the kidney disease composite (HR, 0.77; 95% CI, 0.61-0.98). Associations with ESRD (HR, 1.01; 95% CI, 0.65-1.55) were not significant. Results were qualitatively similar in adjusted analyses of the full population. Two cases of lactic acidosis were observed. CONCLUSIONS Metformin may be safer for use in CKD than previously considered and may lower the risk of death and cardiovascular events in individuals with stage 3 CKD.
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Affiliation(s)
- David M Charytan
- Nephrology Division, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Giuseppe Remuzzi
- Division of Nephrology, L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy and Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - Janet B McGill
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, Missouri
| | - Hans-Henrik Parving
- Division of Endocrinology, Metabolism and Lipid Research, Rigshospitalet Copenhagen University Hospital, Copehnahgen, Denmark
| | - Patrick Parfrey
- Division of Nephrology, Health Sciences Centre, St. John's, Canada
| | - Ajay K Singh
- Nephrology Division, Department of Medicine, NYU Langone Medical Center, New York, New York
| | - Emmanuel A Burdmann
- Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - John J V McMurray
- Division of Cardiology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Larry A Weinrauch
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jiankang Liu
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eldrin F Lewis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc A Pfeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
With the increasing age of the general population, medical conditions necessitating a surgical intervention will increase. Concomitant with advanced age, the prevalence of type 2 diabetes mellitus will also increase. These patients have a two- to three-fold higher risk of occurrence of cardiovascular events and are at higher risk of perioperative myocardial ischemia. This review will discuss recent advances in the field of perioperative cardioprotection and focus specifically on strategies that have aimed to protect the diabetic and the aged myocardium. This review will not deal with potential putative cardioprotective effects of opioids and anesthetic agents, as this is a very broad area that would necessitate a dedicated overview.
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Affiliation(s)
- Mona Momeni
- Department of Anesthesiology & Acute Medicine, Cliniques universitaires Saint Luc, Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle de Recherche Cardiovasculaire, Avenue Hippocrate, Brussels, 1200, Belgium
| | - Stefan De Hert
- Department of Anesthesiology & Perioperative Medicine, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
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72
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Kuan W, Beavers CJ, Guglin ME. Still sour about lactic acidosis years later: role of metformin in heart failure. Heart Fail Rev 2019; 23:347-353. [PMID: 28868582 DOI: 10.1007/s10741-017-9649-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Metformin remains a widely-used, first-line pharmacotherapy agent for patients with type 2 diabetes mellitus because of its efficacy, mild side effects, and affordability.However, use of this medication has traditionally been shunned by clinicians in patient populations that are considered at risk of lactic acidosis, such as those with heart failure. The underutilization of metformin can largely be attributed to the historical stigma of its biguanide predecessor, phenformin, and its association with lactic acidosis. Despite various studies finding low rates of lactic acidosis and the United States Federal Drug Administration's subsequent removal of heart failure from metformin's contraindication labeling in 2006, this oral hypoglycemic remains underutilized in this patient population. In addition to reports of the safe use of metformin in the heart failure population, a multitude of studies have also additionally suggested a modest reduction in mortality and morbidity. Metformin's role should be strongly reconsidered in the armamentarium of diabetes management in heart failure patients.
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Affiliation(s)
- William Kuan
- Department of Pharmacy Services, University of Kentucky Albert B. Chandler Hospital, 800 Rose Street, Room H110, Lexington, KY, 40536, USA.
| | - Craig J Beavers
- Department of Pharmacy Services, University of Kentucky Albert B. Chandler Hospital, 800 Rose Street, Room H110, Lexington, KY, 40536, USA
| | - Maya E Guglin
- Division of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky Albert B. Chandler Hospital, 800 Rose Street, Lexington, KY, 40536, USA
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73
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Wemrell M, Bennet L, Merlo J. Understanding the complexity of socioeconomic disparities in type 2 diabetes risk: a study of 4.3 million people in Sweden. BMJ Open Diabetes Res Care 2019; 7:e000749. [PMID: 31798898 PMCID: PMC6861116 DOI: 10.1136/bmjdrc-2019-000749] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/13/2019] [Accepted: 10/01/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Investigating demographic and socioeconomic factors as intersecting rather than as separate dimensions may improve our understanding of the heterogeneous distribution of type 2 diabetes in the population. However, this complexity has scarcely been investigated and we still do not know the accuracy of these factors for predicting type 2 diabetes. Improved understanding of the demographic and socioeconomic disparities predicting type 2 diabetes risk in the population would contribute to more precise and effective public health interventions. RESEARCH DESIGN AND METHODS We analyzed the risk of type 2 diabetes among 4 334 030 individuals aged 40-84 years who by 2010 had resided in Sweden for at least 5 years. We stratified the study population into 120 strata defined by categories of age, gender, income, education, and immigration status. We calculated measures of absolute risk (prevalence) and relative risk (prevalence ratio), and quantified the discriminatory accuracy of the information for predicting type 2 diabetes in the population. RESULTS The distribution of type 2 diabetes risk in the population was highly heterogeneous. For instance, immigrated men aged 70-79 years with low educational achievement and low income had a risk around 32 times higher than native women aged 40-49 years with high income and high educational achievement (ie, 17.6% vs 0.5%). The discriminatory accuracy of the information was acceptable. CONCLUSION A more detailed, intersectional mapping of socioeconomic and demographic distribution of type 2 diabetes can assist in public health management aiming to reduce the prevalence of the disease.
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Affiliation(s)
- Maria Wemrell
- Unit for Social Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Gender Studies, Lund University, Lund, Sweden
| | - Louise Bennet
- Unit for Family and Community Medicine, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Center for Primary Health Care Research, Region Skåne, Malmö, Sweden
| | - Juan Merlo
- Unit for Social Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Center for Primary Health Care Research, Region Skåne, Malmö, Sweden
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74
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Corremans R, Vervaet BA, D'Haese PC, Neven E, Verhulst A. Metformin: A Candidate Drug for Renal Diseases. Int J Mol Sci 2018; 20:E42. [PMID: 30583483 PMCID: PMC6337137 DOI: 10.3390/ijms20010042] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 12/12/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022] Open
Abstract
Over the past decades metformin has been the optimal first-line treatment for type 2 diabetes mellitus (T2DM). Only in the last few years, it has become increasingly clear that metformin exerts benign pleiotropic actions beyond its prescribed use and ongoing investigations focus on a putative beneficial impact of metformin on the kidney. Both acute kidney injury (AKI) and chronic kidney disease (CKD), two major renal health issues, often result in the need for renal replacement therapy (dialysis or transplantation) with a high socio-economic impact for the patients. Unfortunately, to date, effective treatment directly targeting the kidney is lacking. Metformin has been shown to exert beneficial effects on the kidney in various clinical trials and experimental studies performed in divergent rodent models representing different types of renal diseases going from AKI to CKD. Despite growing evidence on metformin as a candidate drug for renal diseases, in-depth research is imperative to unravel the molecular signaling pathways responsible for metformin's renoprotective actions. This review will discuss the current state-of-the-art literature on clinical and preclinical data, and put forward potential cellular mechanisms and molecular pathways by which metformin ameliorates AKI/CKD.
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Affiliation(s)
- Raphaëlle Corremans
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, 2000 Antwerp, Belgium.
| | - Benjamin A Vervaet
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, 2000 Antwerp, Belgium.
| | - Patrick C D'Haese
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, 2000 Antwerp, Belgium.
| | - Ellen Neven
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, 2000 Antwerp, Belgium.
| | - Anja Verhulst
- Laboratory of Pathophysiology, Department of Biomedical Sciences, University of Antwerp, 2000 Antwerp, Belgium.
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Trinkley KE, Anderson HD, Nair KV, Malone DC, Saseen JJ. Assessing the incidence of acidosis in patients receiving metformin with and without risk factors for lactic acidosis. Ther Adv Chronic Dis 2018; 9:179-190. [PMID: 30181847 PMCID: PMC6116083 DOI: 10.1177/2040622318779760] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 04/27/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Despite strong recommendations to use metformin as first-line therapy for type 2 diabetes (T2DM), its use has been suboptimal, likely due to concerns of lactic acidosis. This study compared the association of acidosis in patients with T2DM prescribed metformin with those prescribed other antihyperglycemic medications or no medications. METHODS This was a retrospective cohort study of patients with newly diagnosed T2DM utilizing an administrative database, which includes medical and prescription claims. Eligible patients had a diagnosis of T2DM, had continuous health plan enrollment 3 months prior to study enrollment and during the study period, and were at least 18 years of age. Mutually exclusive exposure groups were metformin only, other antihyperglycemic medications, and no medication. Acidosis cases were stratified by exposure group and risk factors for lactic acidosis (chronic obstructive pulmonary disease, hepatic dysfunction, alcohol abuse, heart failure, renal insufficiency, age of 80 years or older, and a history of acidosis). Degree of renal insufficiency was not available. Associations between exposure and acidosis were estimated, and risk factors evaluated. RESULTS A total of 132,780 patients met inclusion criteria: 24,936 (20%) metformin only group, 15,059 (11%) other antihyperglycemic medication group, and 92,785 (70%) no medication group. Acidosis was observed in 1.45 per 10,000 patient months (0.78 metformin, 1.59 other antihyperglycemic medication, 1.51 no medication). The unadjusted relative risk of acidosis was 0.5 for patients prescribed metformin only compared with the other exposure groups (95% confidence interval = 0.2-1.2). There was no significant difference in risk of acidosis between exposure groups, irrespective of risk factors for lactic acidosis. CONCLUSIONS Risk of acidosis was similar with metformin only compared with those prescribed other antihyperglycemic medications or no medication. These results support expanded use of metformin for T2DM. Additional studies are needed to understand the impact of risk factor severity on risk of lactic acidosis.
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Affiliation(s)
- Katy E. Trinkley
- University of Colorado Skaggs School of Pharmacy
and Pharmaceutical Sciences and School of Medicine, 12850 E Montview Blvd,
Mail Stop C238, Aurora, CO 80045, USA
| | - Heather D. Anderson
- University of Colorado Skaggs School of Pharmacy
and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kavita V. Nair
- University of Colorado Skaggs School of Pharmacy
and Pharmaceutical Sciences, Aurora, CO, USA
| | | | - Joseph J. Saseen
- University of Colorado Skaggs School of Pharmacy
and Pharmaceutical Sciences, Aurora, CO, USA
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76
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Campbell JM, Adanichkin N, Kurmis R, Munn Z. Intensive insulin therapy, insulin sensitisers and insulin secretagogues for burns: A systematic review of effectiveness and safety. Burns 2018; 44:1377-1394. [DOI: 10.1016/j.burns.2017.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/25/2017] [Accepted: 09/19/2017] [Indexed: 11/29/2022]
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77
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Vest LS, Koraishy FM, Zhang Z, Lam NN, Schnitzler MA, Dharnidharka VR, Axelrod D, Naik AS, Alhamad TA, Kasiske BL, Hess GP, Lentine KL. Metformin use in the first year after kidney transplant, correlates, and associated outcomes in diabetic transplant recipients: A retrospective analysis of integrated registry and pharmacy claims data. Clin Transplant 2018; 32:e13302. [PMID: 29851159 PMCID: PMC6122956 DOI: 10.1111/ctr.13302] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2018] [Indexed: 12/18/2022]
Abstract
While guidelines support metformin as a therapeutic option for diabetic patients with mild-to-moderate renal insufficiency, the frequency and outcomes of metformin use in kidney transplant recipients are not well described. We integrated national U.S. transplant registry data with records from a large pharmaceutical claims clearinghouse (2008-2015). Associations (adjusted hazard ratio, 95% LCL aHR95% UCL ) of diabetes regimens (with and excluding metformin) in the first year post-transplant with patient and graft survival over the subsequent year were quantified by multivariate Cox regression, adjusted for recipient, donor, and transplant factors and propensity for metformin use. Among 14 144 recipients with pretransplant type 2 diabetes mellitus, 4.7% filled metformin in the first year post-transplant; most also received diabetes comedications. Compared to those who received insulin-based regimens without metformin, patients who received metformin were more likely to be female, have higher estimated glomerular filtration rates, and have undergone transplant more recently. Metformin-based regimens were associated with significantly lower adjusted all-cause (aHR 0.18 0.410.91 ), malignancy-related (aHR 0.45 0.450.99 ), and infection-related (aHR 0.12 0.320.85 ) mortality, and nonsignificant trends toward lower cardiovascular mortality, graft failure, and acute rejection. No evidence of increased adverse graft or patient outcomes was noted. Use of metformin-based diabetes treatment regimens may be safe in carefully selected kidney transplant recipients.
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Affiliation(s)
- L S Vest
- Saint Louis University, St. Louis, MO, USA
| | | | - Z Zhang
- Saint Louis University, St. Louis, MO, USA
| | - N N Lam
- University of Alberta, Edmonton, AB, Canada
| | | | | | | | - A S Naik
- Univ Michigan, Ann Arbor, MI, USA
| | | | | | - G P Hess
- Symphony Health, Conshohocken, PN, USA
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78
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Metformin prevents the development of severe chronic kidney disease and its associated mineral and bone disorder. Kidney Int 2018; 94:102-113. [DOI: 10.1016/j.kint.2018.01.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 01/17/2018] [Accepted: 01/25/2018] [Indexed: 12/15/2022]
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79
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Lazarus B, Wu A, Shin JI, Sang Y, Alexander GC, Secora A, Inker LA, Coresh J, Chang AR, Grams ME. Association of Metformin Use With Risk of Lactic Acidosis Across the Range of Kidney Function: A Community-Based Cohort Study. JAMA Intern Med 2018; 178:903-910. [PMID: 29868840 PMCID: PMC6145716 DOI: 10.1001/jamainternmed.2018.0292] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 01/07/2023]
Abstract
Importance Approximately 1 million patients in the United States with type 2 diabetes mellitus and mild-to-moderate kidney disease do not receive guideline-directed therapy with metformin. This may reflect uncertainty regarding the risk of acidosis in patients with chronic kidney disease. Objective To quantify the association between metformin use and hospitalization with acidosis across the range of estimated glomerular filtration rate (eGFR), accounting for change in eGFR stage over time. Design, Setting, and Participants Community-based cohort of 75 413 patients with diabetes in Geisinger Health System, with time-dependent assessment of eGFR stage from January 2004 until January 2017. Results were replicated in 67 578 new metformin users and 14 439 new sulfonylurea users from 2010 to 2015, sourced from 350 private US health systems. Exposures Metformin use. Main Outcomes and Measures Hospitalization with acidosis (International Classification of Diseases, Ninth Revision, Clinical Modification code of 276.2). Results In the primary cohort (n = 75 413), mean (SD) patient age was 60.4 (15.5) years, and 51% (n = 38 480) of the participants were female. There were 2335 hospitalizations with acidosis over a median follow-up of 5.7 years (interquartile range, 2.5-9.9 years). Compared with alternative diabetes management, time-dependent metformin use was not associated with incident acidosis overall (adjusted hazard ratio [HR], 0.98; 95% CI, 0.89-1.08) or in patients with eGFR 45 to 59 mL/min/1.73 m2 (adjusted HR, 1.16; 95% CI, 0.95-1.41) and eGFR 30 to 44 mL/min/1.73 m2 (adjusted HR, 1.09; 95% CI, 0.83-1.44). On the other hand, metformin use was associated with an increased risk of acidosis at eGFR less than 30 mL/min/1.73 m2 (adjusted HR, 2.07; 95% CI, 1.33-3.22). Results were consistent when new metformin users were compared with new sulfonylurea users (adjusted HR for eGFR 30-44 mL/min/1.73 m2, 0.77; 95% CI, 0.29-2.05), in a propensity-matched cohort (adjusted HR for eGFR 30-44 mL/min/1.73 m2, 0.71; 95% CI, 0.45-1.12), when baseline insulin users were excluded (adjusted HR for eGFR 30-44 mL/min/1.73 m2, 1.16; 95% CI, 0.87-1.57), and in the replication cohort (adjusted HR for eGFR 30-44 mL/min/1.73 m2, 0.86; 95% CI, 0.37-2.01). Conclusions and Relevance In 2 real-world clinical settings, metformin use was associated with acidosis only at eGFR less than 30 mL/min/1.73 m2. Our results support cautious use of metformin in patients with type 2 diabetes and eGFR of at least 30 mL/min/1.73 m2.
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Affiliation(s)
- Benjamin Lazarus
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of Nephrology, Monash Medical Centre, Clayton, Australia
| | - Aozhou Wu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Alex Secora
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Alex R. Chang
- Kidney Health Research Institute, Geisinger Health System, Danville, Pennsylvania
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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80
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Varjabedian L, Bourji M, Pourafkari L, Nader ND. Cardioprotection by Metformin: Beneficial Effects Beyond Glucose Reduction. Am J Cardiovasc Drugs 2018; 18:181-193. [PMID: 29478240 DOI: 10.1007/s40256-018-0266-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Metformin is a biguanide that is widely used as an insulin-sparing agent to treat diabetes. When compared with the general population, diabetics are twice as likely to die from fatal myocardial infarction and congestive heart failure (CHF). There has been a significant concern regarding the use of metformin in patients with CHF because of their higher tendency to develop lactic acidosis. However, large epidemiological trials have reported better cardiovascular prognosis with metformin compared to other glucose-lowering agents among diabetics. Additionally, metformin has reduced the risk of reinfarction and all-cause mortality in patients with coronary artery disease and CHF, respectively. The protection against cardiovascular diseases appears to be independent of the anti-hyperglycemic effects of metformin. These effects are mediated through an increase in 5' adenosine monophosphate-activated protein kinase (AMPK) phosphorylation and by increased phosphorylation of endothelial nitric oxide synthase (eNOS) in cardiomyocytes with an increased production of nitric oxide (NO). Metformin preconditions the heart against ischemia-reperfusion injury and may improve myocardial remodeling after an ischemic insult. The preponderance of evidence currently suggests that metformin is safe in patients with CHF, prompting the Food and Drug Administration to remove CHF as a contraindication from the package insert of all generic metformin preparations. In this narrative, along with a limited meta-analysis of available studies, we have reviewed the pleiotropic (non-glucose-lowering) effects of metformin that potentially contribute to its cardioprotective properties. Additionally, we have reviewed issues surrounding the safety of metformin in patients with cardiac diseases.
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Affiliation(s)
| | - Mohammad Bourji
- Department of Medicine, University at Buffalo, Buffalo, NY, 14203, USA
| | - Leili Pourafkari
- Department of Anesthesiology, University at Buffalo, 77 Goodell Street # 550, Buffalo, NY, 14203, USA
| | - Nader D Nader
- Department of Anesthesiology, University at Buffalo, 77 Goodell Street # 550, Buffalo, NY, 14203, USA.
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Aharaz A, Pottegård A, Henriksen DP, Hallas J, Beck-Nielsen H, Lassen AT. Risk of lactic acidosis in type 2 diabetes patients using metformin: A case control study. PLoS One 2018; 13:e0196122. [PMID: 29738540 PMCID: PMC5940216 DOI: 10.1371/journal.pone.0196122] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 04/06/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Metformin constitutes first-line treatment of type 2 diabetes mellitus. It is presumed to have lactic acidosis as a dangerous, but rare, side effect. OBJECTIVES To estimate the incidence rate of lactic acidosis in patients with type 2 diabetes mellitus as well as to estimate the relative risk of lactic acidosis associated with metformin treatment. METHODS This is a population-based combined cohort and case-control study among patients with type 2 diabetes mellitus who were acutely admitted with lactic acidosis at Odense University Hospital, Denmark; in the period from 1st June 2009 to 1st October 2013. The patients included as cases were all acutely hospitalized with lactic acidosis (pH <7.35 and lactate ≥2.0 mmol/l). For each case, we identified 24 age- and sex-matched controls sampled from the same cohort with type 2 diabetes mellitus. The use of metformin identified by using a prescription database. Analyses included multivariable logistic regression and adjusting for predefined confounding: renal function, HbA1c, comorbidity and diabetes duration. RESULTS Our cohort included 10,652 patients with type 2 diabetes mellitus with a median age of 74 years, and 51.5% were male. During follow-up, 163 individuals were hospitalized with lactic acidosis, corresponding to an incidence rate of 391/100,000 person years. Use of metformin was not associated with lactic acidosis: adjusted odds ratio was 0.79 (95%CI 0.54-1.17). CONCLUSION Among patients with type 2 diabetes mellitus, the incidence rate of acute hospitalization with lactic acidosis was 391/100,000 person years. Use of metformin did not increase the risk of lactic acidosis. However, comorbidity seems to be an important risk factor.
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Affiliation(s)
- Abdellatif Aharaz
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
| | | | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, University of Southern Denmark, Odense, Denmark
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Malik F, Mehdi SF, Ali H, Patel P, Basharat A, Kumar A, Ashok F, Stein J, Brima W, Malhotra P, Roth J. Is metformin poised for a second career as an antimicrobial? Diabetes Metab Res Rev 2018; 34:e2975. [PMID: 29271563 DOI: 10.1002/dmrr.2975] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 12/24/2022]
Abstract
Metformin, a widely used antihyperglycaemic, has a good safety profile, reasonably manageable side-effects, is inexpensive, and causes a desirable amount of weight loss. In 4 studies of patients with tuberculosis (1 prospective and 3 retrospective), metformin administration resulted in better outcomes. In mice with several models of endotoxemia, metformin diminished levels of proinflammatory cytokines and improved survival. Laboratory studies showed effectiveness of the drug on multiple pathogens, including Trichinella spiralis, Staphylococcus aureus, Pseudomonas aeruginosa, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. Metformin administration in humans and mice produced major changes in the composition of the gut microbiota. These recently discovered microbe-modulating properties of the drug have led investigators to predict wide therapeutic utility for metformin. The recent easing in United States Food and Drug Administration (FDA) guidelines regarding administration of metformin to patients with kidney disease, and reduced anxiety about patient safety in terms of lactic acidosis, increase the probability of broadening of metformin's usage as a treatment of infectious agents. In this text we review articles pertinent to metformin's effects on microorganisms, both pathogens and commensals. We highlight the possible role of metformin in a wide range of infectious diseases and a possible expansion of its therapeutic profile in this field. A systematic review was done of PubMed indexed articles that examined the effects of metformin on a wide range of pathogens. Metformin was found to have efficacy as an antimicrobial agent in patients with tuberculosis. Mice infected with Trypanosomiasis cruzi had higher survival when also treated with metformin. The drug in vitro was active against T. spiralis, S. aureus, P. aeruginosa, and hepatitis B virus. In addition there is emerging literature on its role in sepsis. We conclude that metformin may have a potential role in the therapy for multiple infectious diseases. Metformin, in addition to its traditional effects on glucose metabolism, provides anti-microbial benefits in patients with tuberculosis and in a very wide range of other infections encounters in vitro and in vivo.
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Affiliation(s)
- Faiza Malik
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Syed Faizan Mehdi
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Haroon Ali
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Priya Patel
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Anam Basharat
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Amrat Kumar
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Fnu Ashok
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Joanna Stein
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Wunnie Brima
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Prashant Malhotra
- Division of Infectious Diseases, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jesse Roth
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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Abstract
Metformin has been associated with lactic acidosis. Lactate levels are not commonly tested in clinical practice, and it is unclear to what extent metformin would typically increase lactate levels with chronic use. The aim of this review was to determine whether regular monitoring of the plasma lactate level would be beneficial in avoiding lactate accumulation and, ultimately, minimising the incidence of lactic acidosis in metformin-treated patients.A comprehensive search of PubMed, Embase, Web of Science, Cochrane and International Pharmaceutical Abstracts databases covering the period up to 30 May 2017 was performed. Search terms included combinations of terms and keywords, including "metformin", "lactate", "lactic acid" and "lactic acidosis". Cases series of lactic acidosis or metformin-associated lactic acidosis were excluded.Of 1539 potentially relevant articles, a total of 52 reported lactate levels from routine/regular pathological tests in metformin users. The studies were subdivided into four themes, regarding metformin usage and the reported lactate levels in patients who: (1) did not have contraindications to the use of metformin; (2) had contraindications, or renal impairment but without other contraindications; (3) exercised; or (4) also received any nucleoside reverse transcriptase inhibitor. Studies have reported that metformin treatment could increase lactate level of users. However, most results showed that the lactate level remained in the normal range.No definitive conclusions on the benefits of regular lactate monitoring in patients taking metformin can be made. Future research on larger populations focusing on the measurement of lactate levels with continuous metformin use is warranted.
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Karlsson SA, Hero C, Svensson AM, Franzén S, Miftaraj M, Gudbjörnsdottir S, Eeg-Olofsson K, Eliasson B, Andersson Sundell K. Association between refill adherence to lipid-lowering medications and the risk of cardiovascular disease and mortality in Swedish patients with type 2 diabetes mellitus: a nationwide cohort study. BMJ Open 2018; 8:e020309. [PMID: 29602853 PMCID: PMC5884334 DOI: 10.1136/bmjopen-2017-020309] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To analyse the association between refill adherence to lipid-lowering medications, and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes mellitus. DESIGN Cohort study. SETTING National population-based cohort of Swedish patients with type 2 diabetes mellitus. PARTICIPANTS 86 568 patients aged ≥18 years, registered with type 2 diabetes mellitus in the Swedish National Diabetes Register, who filled at least one prescription for lipid-lowering medication use during 2007-2010, 87% for primary prevention. EXPOSURE AND OUTCOME MEASURES Refill adherence of implementation was assessed using the medication possession ratio (MPR), representing the proportion of days with medications on hand during an 18-month exposure period. MPR was categorised by five levels (≤20%, 21%-40%, 41%-60%, 61%-80% and >80%). Patients without medications on hand for ≥180 days were defined as non-persistent. Risk of CVD (myocardial infarction, ischaemic heart disease, stroke and unstable angina) and mortality by level of MPR and persistence was analysed after the exposure period using Cox proportional hazards regression and Kaplan-Meier, adjusted for demographics, socioeconomic status, concurrent medications and clinical characteristics. RESULTS The hazard ratios for CVD ranged 1.33-2.36 in primary prevention patients and 1.19-1.58 in secondary prevention patients, for those with MPR ≤80% (p<0.0001). The mortality risk was similar regardless of MPR level. The CVD risk was 74% higher in primary prevention patients and 33% higher in secondary prevention patients, for those who were non-persistent (p<0.0001). The mortality risk was 6% higher in primary prevention patients and 18% higher in secondary prevention patients, for non-persistent patients (p<0.0001). CONCLUSIONS Higher refill adherence to lipid-lowering medications was associated with lower risk of CVD in primary and secondary prevention patients with type 2 diabetes mellitus.
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Affiliation(s)
- Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christel Hero
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- AstraZeneca, Medical Evidence and Observational Research, Gothenburg, Sweden
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85
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[Essence and Perspective of the JGS/JDS Clinical Practice Guideline for the Treatment of Diabetes in the Elderly]. Nihon Ronen Igakkai Zasshi 2018; 55:1-12. [PMID: 29503351 DOI: 10.3143/geriatrics.55.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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86
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Htun HL, Yeo TW, Tam CC, Pang J, Leo YS, Lye DC. Metformin Use and Severe Dengue in Diabetic Adults. Sci Rep 2018; 8:3344. [PMID: 29463812 PMCID: PMC5820327 DOI: 10.1038/s41598-018-21612-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 02/02/2018] [Indexed: 01/07/2023] Open
Abstract
Diabetes mellitus is a risk factor for severe dengue in adults, but few studies have examined the association between metformin use and disease severity in dengue. In addition to its effect on glucose control, metformin has been associated with pleiotropic properties in preclinical studies. Using a cohort of laboratory-confirmed adult (≥21 years) dengue patients with diabetes mellitus admitted to Tan Tock Seng Hospital, we conducted a retrospective cohort study involving 131 (58.7%) metformin users and 92 (41.3%) non-users. Dengue severity was categorized as dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) in World Health Organization (WHO) 1997 criteria and severe dengue (SD) in WHO 2009 criteria. Multivariable Poisson regression with robust error variance was used to estimate risk ratio (RR). Compared with non-use, metformin use was associated with a decreased risk of developing severe dengue (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI]: 0.37–0.98, P = 0.04). Additionally, there was an inverse dose-response relationship (aRR = 0.69, 95% CI: 0.49–0.98, P = 0.04) with dengue severity as classified by WHO 2009 criteria. Use of metformin, however, was not associated with dengue severity based on WHO 1997 criteria; and no dose-response relationship was noted. Our results suggest metformin use could attenuate disease severity in dengue-infected diabetes mellitus individuals.
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Affiliation(s)
- Htet Lin Htun
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Tsin Wen Yeo
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Clarence C Tam
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Junxiong Pang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Yee Sin Leo
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - David C Lye
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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87
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Mortality Associated with Metformin Versus Sulfonylurea Initiation: A Cohort Study of Veterans with Diabetes and Chronic Kidney Disease. J Gen Intern Med 2018; 33:155-165. [PMID: 29181788 PMCID: PMC5789109 DOI: 10.1007/s11606-017-4219-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/22/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND For patients with type 2 diabetes and chronic kidney disease (CKD), high-quality evidence about the relative benefits and harms of oral glucose-lowering drugs is limited. OBJECTIVE To evaluate whether mortality risk differs after the initiation of monotherapy with either metformin or a sulfonylurea in Veterans with type 2 diabetes and CKD. DESIGN Observational, national cohort study in the Veterans Health Administration (VHA). PARTICIPANTS Veterans who received care from the VHA for at least 1 year prior to initiating monotherapy treatment for type 2 diabetes with either metformin or a sulfonylurea between 2004 and 2009. MAIN MEASURES Metformin and sulfonylurea use was assessed from VHA electronic pharmacy records. The CKD-EPI equation was used to estimate glomerular filtration rate (eGFR). The outcome of death from January 1, 2004, through December 31, 2009, was assessed from VHA Vital Status files. KEY RESULTS Among 175,296 new users of metformin or a sulfonylurea monotherapy, 5121 deaths were observed. In primary analyses adjusted for all measured potential confounding factors, metformin monotherapy was associated with a lower mortality hazard ratio (HR) compared with sulfonylurea monotherapy across all ranges of eGFR evaluated (HR ranging from 0.59 to 0.80). A secondary analysis of mortality risk differences favored metformin across all eGFR ranges; the greatest risk difference was observed in the eGFR category 30-44 mL/min/1.73m2 (12.1 fewer deaths/1000 person-years, 95% CI 5.2-19.0). CONCLUSIONS Initiation of metformin versus a sulfonylurea among individuals with type 2 diabetes and CKD was associated with a substantial reduction in mortality, in terms of both relative and absolute risk reduction. The largest absolute risk reduction was observed among individuals with moderately-severely reduced eGFR (30-44 mL/min/1.73m2).
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88
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Abstract
Objective: The Food and Drug Administration recently updated metformin prescribing recommendations for patients with diabetes and renal disease. The American Diabetes Association as well as the American Association of Clinical Endocrinologists and American Clinical Endocrinologists also recommend periodic monitoring of vitamin B12 levels for patients using metformin. A review of the literature was conducted to assess data to evaluate the recent updates to metformin usage and provide rationales for these recommendations. Data Sources: PubMed MESH terms "Diabetes Mellitus, Type 2" and "Renal Insufficiency, Chronic" and "Metformin" were searched with an English limitation from 1990 to May 2017. A MEDLINE search was conducted using the terms "metformin" and "renal disease" from 1990 to May 2017. A PubMed search was conducted using the MESH terms "vitamin b12 deficiency" and "metformin" from 1970 to May 2017. A MEDLINE search was conducted using terms "metformin" and "vitamin B12 deficiency" with an English limitation from 1970 to May 2017. Study Selection and Data Extraction: Retrospective and prospective clinical trials, meta-analyses, and systematic reviews were considered for inclusion. Citations from identified articles were also reviewed for inclusion. Data Synthesis: The incidence of metformin-associated lactic acidosis is minimal. Data indicate metformin-treated patients with an estimated glomerular filtration rate above 30 mL/min/1.73 m2 have a reduction in mortality. Additionally, data suggest metformin may lead to vitamin B12 deficiency. Conclusion: Data support recommendations for metformin use in patients with diabetes and renal insufficiency with an estimated glomerular filtration rate above 30 mL/min/1.73 m2. Data also suggest that baseline and periodic testing of vitamin B12 levels are warranted and supported by clinical guidelines due to the risk of vitamin B12 deficiency in metformin-treated patients.
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Affiliation(s)
- Andrea C. Wooley
- Southern Illinois University
Edwardsville, Edwardsville, IL, USA
- Southern Illinois Healthcare Foundation,
Centreville, IL, USA
| | - Jessica L. Kerr
- Southern Illinois University
Edwardsville, Edwardsville, IL, USA
- St. Louis Veterans Affairs Medical
Center, Belleville Community Based Outpatient Clinic, Belleville, IL, USA
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89
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Rogacka D, Audzeyenka I, Rychłowski M, Rachubik P, Szrejder M, Angielski S, Piwkowska A. Metformin overcomes high glucose-induced insulin resistance of podocytes by pleiotropic effects on SIRT1 and AMPK. Biochim Biophys Acta Mol Basis Dis 2018; 1864:115-125. [DOI: 10.1016/j.bbadis.2017.10.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/08/2017] [Accepted: 10/11/2017] [Indexed: 01/09/2023]
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90
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De Broe M, Kajbaf F, Lalau JD. Renoprotective Effects of Metformin. Nephron Clin Pract 2017; 138:261-274. [DOI: 10.1159/000481951] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/03/2017] [Indexed: 12/18/2022] Open
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91
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Rhee CM, Kalantar-Zadeh K. Further clarifying the relationship between metformin, acute kidney injury and lactic acidosis. Nat Rev Nephrol 2017; 14:70. [PMID: 29234161 DOI: 10.1038/nrneph.2017.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California 92868, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, California 92868, USA; and at the Tibor Rubin Veterans Affairs Medical Center, Long Beach, California 90822, USA
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92
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Bell S, Soto-Pedre E, Connelly P, Livingstone S, Pearson E. Clarifying the relationship between metformin, acute kidney injury and lactic acidosis. Nat Rev Nephrol 2017; 14:70. [PMID: 29234163 DOI: 10.1038/nrneph.2017.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Samira Bell
- Renal Unit, Ninewells Hospital, Dundee DD1 9SY, UK; and at Population Health Sciences, School of Medicine, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Enrique Soto-Pedre
- Division of Molecular & Clinical Medicine, Level 5, Mailbox 12, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - Paul Connelly
- Division of Molecular & Clinical Medicine, Level 5, Mailbox 12, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - Shona Livingstone
- Population Health Sciences, School of Medicine, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Ewan Pearson
- Division of Molecular & Clinical Medicine, Level 5, Mailbox 12, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
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93
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Connelly PJ, Lonergan M, Soto‐Pedre E, Donnelly L, Zhou K, Pearson ER. Acute kidney injury, plasma lactate concentrations and lactic acidosis in metformin users: A GoDarts study. Diabetes Obes Metab 2017; 19:1579-1586. [PMID: 28432751 PMCID: PMC5655780 DOI: 10.1111/dom.12978] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/09/2017] [Accepted: 04/18/2017] [Indexed: 12/21/2022]
Abstract
AIMS Metformin is renally excreted and has been associated with the development of lactic acidosis. Although current advice is to omit metformin during illnesses that may increase the risk of acute kidney injury (AKI), the evidence supporting this is lacking. We investigated the relationship between AKI, lactate concentrations and the risk of lactic acidosis in those exposed to metformin. MATERIALS AND METHODS We undertook a population-based case-control study of lactic acidosis in 1746 participants with Type 2 diabetes and 846 individuals without diabetes with clinically measured lactates with and without AKI between 1994 and 2014. AKI was stratified by severity according to "Kidney Disease: Improving Global Outcomes" guidelines. Mixed-effects logistic and linear regression were used to analyse lactic acidosis risk and lactate concentrations, respectively. RESULTS Eighty-two cases of lactic acidosis were identified. In Type 2 diabetes, those treated with metformin had a greater incidence of lactic acidosis [45.7 per 100 000 patient years; 95% confidence interval (CI) 35.9-58.3] compared to those not exposed to this drug (11.8 per 100 000 patient years; 95% CI 4.9-28.5). Lactate concentrations were 0.34 mmol/L higher in the metformin-exposed cohort (P < .001). The risk of lactic acidosis was higher in metformin users [odds ratio (OR) 2.3; P = .002] and increased with AKI severity (stage 1: OR 3.0, P = .002; stage 2: OR 9.4, P < .001; stage 3: OR 16.1, P < .001). CONCLUSIONS A clear association was found between metformin, lactate accumulation and the development of lactic acidosis. This relationship is strongest in those with AKI. These results provide robust evidence to support current recommendations to omit metformin in any illness that may precipitate AKI.
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Affiliation(s)
- Paul J. Connelly
- Division of Molecular and Clinical Medicine, School of MedicineUniversity of DundeeDundeeUK
| | - Mike Lonergan
- Division of Molecular and Clinical Medicine, School of MedicineUniversity of DundeeDundeeUK
| | - Enrique Soto‐Pedre
- Division of Molecular and Clinical Medicine, School of MedicineUniversity of DundeeDundeeUK
| | - Louise Donnelly
- Division of Molecular and Clinical Medicine, School of MedicineUniversity of DundeeDundeeUK
| | - Kaixin Zhou
- Division of Molecular and Clinical Medicine, School of MedicineUniversity of DundeeDundeeUK
| | - Ewan R. Pearson
- Division of Molecular and Clinical Medicine, School of MedicineUniversity of DundeeDundeeUK
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94
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Karlsson SA, Hero C, Eliasson B, Franzén S, Svensson AM, Miftaraj M, Gudbjörnsdottir S, Eeg-Olofsson K, Andersson Sundell K. Refill adherence and persistence to lipid-lowering medicines in patients with type 2 diabetes: A nation-wide register-based study. Pharmacoepidemiol Drug Saf 2017; 26:1220-1232. [PMID: 28799214 PMCID: PMC5656892 DOI: 10.1002/pds.4281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 04/27/2017] [Accepted: 07/04/2017] [Indexed: 12/21/2022]
Abstract
Purpose This study aimed to describe and compare refill adherence and persistence to lipid‐lowering medicines in patients with type 2 diabetes by previous cardiovascular disease (CVD). Methods We followed 97 595 patients (58% men; 23% with previous CVD) who were 18 years of age or older when initiating lipid‐lowering medicines in 2007–2010 until first fill of multi‐dose dispensed medicines, death, or 3 years. Using personal identity numbers, we linked individuals' data from the Swedish Prescribed Drug Register, the Swedish National Diabetes Register, the National Patient Register, the Cause of Death Register, and the Longitudinal Integration Database for Health Insurance and Labour Market Studies. We assessed refill adherence using the medication possession ratio (MPR) and the maximum gap method, and measured persistence from initiation to discontinuation of treatment or until 3 years after initiation. We analyzed differences in refill adherence and persistence by previous CVD in multiple regression models, adjusted for socioeconomic status, concurrent medicines, and clinical characteristics. Results The mean age of the study population was 64 years, 80% were born in Sweden, and 56% filled prescriptions for diabetes medicines. Mean MPR was 71%, 39% were adherent according to the maximum gap method, and mean persistence was 758 days. Patients with previous CVD showed higher MPR (3%) and lower risk for discontinuing treatment (12%) compared with patients without previous CVD (P < 0.0001). Conclusions Patients with previous CVD were more likely to be adherent to treatment and had lower risk for discontinuation compared with patients without previous CVD.
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Affiliation(s)
- Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Christel Hero
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,AstraZeneca AB, Medical Evidence and Observational Research, Gothenburg, Sweden
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95
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Rhee CM, Kalantar-Zadeh K. Diabetes mellitus: Complex interplay between metformin, AKI and lactic acidosis. Nat Rev Nephrol 2017; 13:521-522. [PMID: 28736433 DOI: 10.1038/nrneph.2017.105] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, California 92868, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, California 92868, USA.,Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, California 92868, USA; and at the Tibor Rubin Veterans Affairs Medical Center, 5901 E 7 th Street, Long Beach, California 90822, USA
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96
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Gentile S, Piscitelli P, Viazzi F, Russo G, Ceriello A, Giorda C, Guida P, Fioretto P, Pontremoli R, Strollo F, De Cosmo S. Antihyperglycemic treatment in patients with type 2 diabetes in Italy: the impact of age and kidney function. Oncotarget 2017; 8:62039-62048. [PMID: 28977924 PMCID: PMC5617484 DOI: 10.18632/oncotarget.18816] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/10/2017] [Indexed: 11/25/2022] Open
Abstract
We describe AHA utilization pattern according to age and renal function in type 2 diabetes mellitus (T2DM), in real-life conditions. The analysis was performed using the data set of electronic medical records collected between 1 January and 31 December, 2011 in 207 Italian diabetes centers. The study population consisted of 157,595 individuals with T2DM. The AHA treatment regimens was evaluated. Kidney function was assessed by eGFR, estimated using the CKD-EPI formula. Other determinations: HbA1c, blood pressure (BP), low- density lipoprotein (LDL-c), total and high density lipoprotein cholesterol (TC and HDL-c), triglycerides (TG) and serum uric acid (SUA). Quality of care was assessed through Q score. The proportion of subjects taking metformin declined progressively across age quartiles along with eGFR values, but remained high in oldest subjects (i.e. 54.5 %). On the other hand, the proportion of patients on secretagogues or insulin increased with aging (i.e. 54.7% and 37% in the fourth age quartile, respectively). The percentage of patients with low eGFR (i.e. <30 ml/min/1.73m2) taking either metformin or sulphonilureas/repaglinide was particularly high (i.e. 15.3% and 34.3% respectively). In a large real-life cohort of T2DM, metformin or sulphonylureas/repaglinide, although not recommended, are frequently prescribed to elderly subjects with severe kidney disease.
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Affiliation(s)
- Sandro Gentile
- Department of Clinical and Experimental Medicine, University of Campania, Naples, Italy
| | - Pamela Piscitelli
- IRCSS Casa Sollievo della Sofferenza - Unit of Internal Medicine, Scientific Institute, San Giovanni Rotondo, Italy
| | - Francesca Viazzi
- Università degli Studi, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
| | - Giuseppina Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Ceriello
- Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain.,U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS, Milano, Italy
| | - Carlo Giorda
- Diabetes and Metabolism Unit, ASL Turin 5, Turin, Italy
| | - Piero Guida
- Statistical Consultant for Associazione Medici Diabetologi (AMD), Rome, Italy
| | - Paola Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - Roberto Pontremoli
- Università degli Studi, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Istituto Nazionale per la Ricerca sul Cancro, Genova, Italy
| | | | - Salvatore De Cosmo
- IRCSS Casa Sollievo della Sofferenza - Unit of Internal Medicine, Scientific Institute, San Giovanni Rotondo, Italy
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97
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Abstract
OBJECTIVE Metformin is the most commonly prescribed drug for the treatment of type 2 diabetes because of its apparent robust effects in reducing cardiovascular risk. This review examines the current literature regarding the nonglycemic effects and potential novel indications for metformin. METHODS Review of the literature, with a focus on metformin use in Stage 3 chronic kidney disease (CKD-3) and heart failure (HF). RESULTS The United Kingdom Prospective Diabetes Study suggests that metformin reduces the risk of myocardial infarction, and more recent retrospective studies have shown an association between metformin use and a reduction in stroke, atrial fibrillation and all-cause mortality. The mechanism(s) explaining these putative benefits are not clear but may involve decreased energy intake (with attendant weight loss), improvement in lipids, and lowering of blood pressure; a literature review suggests that metformin lowers blood pressure when it is elevated, but not when it is normal. Metformin appears to be safe when given to patients with CKD-3. In addition, there is evidence that individuals with CKD-3, who are at increased cardiovascular risk, stand to benefit from metformin therapy. Lactic acidosis is an extremely remote and probably avoidable risk; measurement of plasma metformin levels and more frequent monitoring of renal function may be useful in selected patients with CKD-3 who are treated with metformin. Finally, there is evidence that metformin is safe in patients with HF; metformin therapy is associated with a reduction in newly incident HF and in HF mortality. CONCLUSION Metformin has a dominant position in the treatment of type 2 diabetes that is deserved due to its favorable and robust effects on cardiovascular risk. ABBREVIATIONS AMP = adenosine monophosphate BP = blood pressure CKD = chronic kidney disease CKD-3 = Stage 3 CKD eGFR = estimated glomerular filtration rate HDL = high-density lipoprotein HF = heart failure MAP = mean arterial pressure mVO2 = myocardial oxygen consumption T2DM = type 2 diabetes mellitus UKPDS = United Kingdom Prospective Diabetes Study.
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98
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Bell S, Farran B, McGurnaghan S, McCrimmon RJ, Leese GP, Petrie JR, McKeigue P, Sattar N, Wild S, McKnight J, Lindsay R, Colhoun HM, Looker H. Risk of acute kidney injury and survival in patients treated with Metformin: an observational cohort study. BMC Nephrol 2017; 18:163. [PMID: 28526011 PMCID: PMC5437411 DOI: 10.1186/s12882-017-0579-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/11/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Whether metformin precipitates lactic acidosis in patients with chronic kidney disease (CKD) remains under debate. We examined whether metformin use was associated with an increased risk of acute kidney injury (AKI) as a proxy for lactic acidosis and whether survival among those with AKI varied by metformin exposure. METHODS All individuals with type 2 diabetes and available prescribing data between 2004 and 2013 in Tayside, Scotland were included. The electronic health record for diabetes which includes issued prescriptions was linked to laboratory biochemistry, hospital admission, death register and Scottish Renal Registry data. AKI events were defined using the Kidney Disease Improving Global Outcomes criteria with a rise in serum creatinine of at least 26.5 μmol/l or a rise of greater than 150% from baseline for all hospital admissions. Cox Regression Analyses were used to examine whether person-time periods in which current metformin exposure occurred were associated with an increased rate of first AKI compared to unexposed periods. Cox regression was also used to compare 28 day survival rates following first AKI events in those exposed to metformin versus those not exposed. RESULTS Twenty-five thousand one-hundred fourty-eight patients were included with a total person-time of 126,904 person years. 4944 (19.7%) people had at least one episode of AKI during the study period. There were 32.4 cases of first AKI/1000pyrs in current metformin exposed person-time periods compared to 44.9 cases/1000pyrs in unexposed periods. After adjustment for age, sex, diabetes duration, calendar time, number of diabetes drugs and baseline renal function, current metformin use was not associated with AKI incidence, HR 0.94 (95% CI 0.87, 1.02, p = 0.15). Among those with incident AKI, being on metformin at admission was associated with a higher rate of survival at 28 days (HR 0.81, 95% CI 0.69, 0.94, p = 0.006) even after adjustment for age, sex, pre-admission eGFR, HbA1c and diabetes duration. CONCLUSIONS Contrary to common perceptions, we found no evidence that metformin increases incidence of AKI and was associated with higher 28 day survival following incident AKI.
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Affiliation(s)
- Samira Bell
- Renal Unit, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Bassam Farran
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Stuart McGurnaghan
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Rory J McCrimmon
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Graham P Leese
- Department of Medicine, University of Dundee, Dundee, UK
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Paul McKeigue
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Sarah Wild
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
| | - John McKnight
- Department of Medicine, Western General Hospital, Edinburgh, UK
| | - Robert Lindsay
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Helen Looker
- Division of Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
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Abstract
PURPOSE OF REVIEW There are currently over 40 different drugs in 12 distinct classes approved in the USA to treat patients with type 2 diabetes mellitus. This review summarizes our current knowledge about potential side effects of antidiabetic therapy and attempts to apply it to a clinical practice setting. RECENT FINDINGS Given the heterogeneity of both the patients and the disease, it is mathematically impossible to test every available drug combination in long-term outcome, prospective, randomized blinded fashion before a clinician decides which agent(s) to prescribe to a specific patient in a given situation. To complicate the clinician's dilemma, there is lack of available tests to predict an individual's response or propensity to side effects. Further, the data available are derived from small, short-term registration trials and typically focus on relative rather than absolute risks of any given drug and do not address the potential adverse outcomes if a patient's diabetes remains untreated. Clinicians have to personalize their choice of antidiabetic therapy based both on the specific characteristics of the patient in front of them (stage of diabetes and its complications, overall health status, socioeconomic situation, other medications present, desire to improve control of diabetes, etc.) and the current knowledge about the relative and absolute balance of benefits and risks of any individual medication in that specific patient. It has to be recognized that this requires constant re-evaluation as database of our experience with antidiabetic therapy expands.
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Affiliation(s)
- George Grunberger
- Grunberger Diabetes Institute, 43494 Woodward Avenue, suite 208, Bloomfield Hills, MI, 48302, USA.
- Internal Medicine and Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI, USA.
- Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
- Internal Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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100
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Imam TH. Changes in metformin use in chronic kidney disease. Clin Kidney J 2017; 10:301-304. [PMID: 28616207 PMCID: PMC5466114 DOI: 10.1093/ckj/sfx017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/21/2017] [Indexed: 01/06/2023] Open
Abstract
Metformin is one of the oldest and most widely prescribed antidiabetic medicines worldwide. It is the only such medicine that has shown a reduction of cardiovascular mortality in diabetes mellitus type 2. Since many diabetic patients have chronic kidney disease, its use is often curtailed by practitioners due to fear of lactic acidosis and the US Food and Drug Administration (FDA) warnings that, until recently, had been in place for decades. Current guidelines, though somewhat vague regarding dosages, clearly pave the way for spreading the use of metformin in patients with lower glomerular filtration rates. These guidelines also suggest moving away from just looking at serum creatinine to create a cut-off. Metformin’s costs are lower, and in many underdeveloped countries this is the only medicine available for poor patients. More widespread use of metformin will further help with health care costs, as well as obesity. It will simplify the use of diabetes mellitus type 2 management with lower incidences of hypoglycemia. With all the mounting evidence, the FDA is finally requiring labeling changes regarding recommendations, to allow the use of metformin in patients with much reduced kidney function.
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Affiliation(s)
- Talha H Imam
- Division of Nephrology, Kaiser Permanente, Southern California Permanente Medical Group, Fontana, CA, USA
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