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Ruiz-Tamayo I, Franch-Nadal J, Mata-Cases M, Mauricio D, Cos X, Rodriguez-Poncelas A, Barrot J, Coll-de-Tuero G, Mundet-Tudurí X. Noninsulin Antidiabetic Drugs for Patients with Type 2 Diabetes Mellitus: Are We Respecting Their Contraindications? J Diabetes Res 2016; 2016:7502489. [PMID: 26881258 PMCID: PMC4736814 DOI: 10.1155/2016/7502489] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 12/16/2015] [Indexed: 11/25/2022] Open
Abstract
AIM To assess prescribing practices of noninsulin antidiabetic drugs (NIADs) in T2DM with several major contraindications according to prescribing information or clinical guidelines: renal failure, heart failure, liver dysfunction, or history of bladder cancer. METHODS Cross-sectional, descriptive, multicenter study. Electronic medical records were retrieved from all T2DM subjects who attended primary care centers pertaining to the Catalan Health Institute in Catalonia in 2013 and were pharmacologically treated with any NIAD alone or in combination. RESULTS Records were retrieved from a total of 255,499 pharmacologically treated patients. 78% of patients with some degree of renal impairment (glomerular filtration rate (GFR) < 60 mL/min) were treated with metformin and 31.2% with sulfonylureas. Even in the event of severe renal failure (GFR < 30 mL/min), 35.3% and 22.5% of patients were on metformin or sulfonylureas, respectively. Moreover, metformin was prescribed to more than 60% of patients with moderate or severe heart failure. CONCLUSION Some NIADs, and in particular metformin, were frequently used in patients at high risk of complications when they were contraindicated. There is a need to increase awareness of potential inappropriate prescribing and to monitor the quality of prescribing patterns in order to help physicians and policymakers to yield better clinical outcomes in T2DM.
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Affiliation(s)
- Irene Ruiz-Tamayo
- Primary Health Care Center La Torrassa, Consorci Sanitari Integral, Ronda Torrassa 151-153, 08903 L'Hospitalet de Llobregat, Spain
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
| | - Josep Franch-Nadal
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- Primary Health Care Center Raval Sud, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Avinguda Drassanes 17-21, 08001 Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Monforte de Lemos 3-5, 28029 Madrid, Spain
- *Josep Franch-Nadal:
| | - Manel Mata-Cases
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Monforte de Lemos 3-5, 28029 Madrid, Spain
- Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Mar S/N, 08930 Sant Adrià de Besòs, Spain
| | - Dídac Mauricio
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Monforte de Lemos 3-5, 28029 Madrid, Spain
- Department of Endocrinology & Nutrition, Health Sciences Research Institute and Hospital Universitari Germans Trias i Pujol, Carretera Canyet S/N, 08916 Badalona, Spain
| | - Xavier Cos
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- Primary Health Care Center Sant Martí de Provençals, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Fluvià 211, 08020 Barcelona, Spain
| | - Antonio Rodriguez-Poncelas
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- Primary Health Care Center Anglès, Gerència d'Àmbit d'Atenció Primària Girona, Institut Català de la Salut, Carretera de Girona S/N, 17160 Anglès, Spain
| | - Joan Barrot
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- Primary Health Care Center Salt, Gerència d'Àmbit d'Atenció Primària Girona, Institut Català de la Salut, Manel de Falla 35, 17190 Salt, Spain
| | - Gabriel Coll-de-Tuero
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- Primary Health Care Center Anglès, Gerència d'Àmbit d'Atenció Primària Girona, Institut Català de la Salut, Carretera de Girona S/N, 17160 Anglès, Spain
| | - Xavier Mundet-Tudurí
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Sardenya 375, 08006 Barcelona, Spain
- Primary Health Care Center El Carmel, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Murtra 130, 08032 Barcelona, Spain
- Autonomous University of Barcelona, Campus de Bellaterra, 08193 Bellaterra, Spain
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102
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Lepelley M, Giai J, Yahiaoui N, Chanoine S, Villier C. Lactic Acidosis in Diabetic Population: Is Metformin Implicated? Results of a Matched Case-Control Study Performed on the Type 2 Diabetes Population of Grenoble Hospital University. J Diabetes Res 2016; 2016:3545914. [PMID: 27034959 PMCID: PMC4789438 DOI: 10.1155/2016/3545914] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/15/2016] [Accepted: 02/08/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION To evaluate the strength of association between lactic acidosis (LA) and well-recognized risk factors for LA, particularly the weight of metformin. METHODS This study is a matched case-control analysis concerning the type 2 diabetes population from Grenoble Hospital University. Cases of LA were defined biologically with pH < 7.35 and lactates > 5 mmol/L. They were matched to 2 controls defined as type 2 diabetic inpatients who did not present a LA during the study period. We performed a conditional logistic regression. RESULTS We included 302 cases and 604 controls; mean age was 69.5 years (SD 11.93). Intercurrent diseases were significantly associated with LA. Chronic medical conditions had a minor impact on LA incidence, except hepatocellular dysfunction. Metformin was significantly associated with a higher LA probability in case of acute kidney injury (AKI) (OR = 1.79; p value = 0.020) but not in patients without AKI. DISCUSSION AND CONCLUSIONS According to this study, metformin, compared to acute medical conditions, seemed not to be associated with LA in patients with type 2 diabetes; however in case of AKI, metformin may be associated with LA.
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MESH Headings
- Acidosis, Lactic/blood
- Acidosis, Lactic/chemically induced
- Acidosis, Lactic/diagnosis
- Acidosis, Lactic/epidemiology
- Acute Kidney Injury/epidemiology
- Aged
- Aged, 80 and over
- Biomarkers/blood
- Case-Control Studies
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/epidemiology
- Female
- France/epidemiology
- Hospitals, University
- Humans
- Hypoglycemic Agents/adverse effects
- Lactic Acid/blood
- Male
- Metformin/adverse effects
- Middle Aged
- Risk Assessment
- Risk Factors
- Treatment Outcome
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Affiliation(s)
- Marion Lepelley
- Centre Régional de Pharmacovigilance, Pôle Santé Publique, Centre Hospitalier Universitaire de Grenoble, 38000 Grenoble, France
- *Marion Lepelley:
| | - Joris Giai
- Service de Biostatistique des Hospices Civils de Lyon, 69002 Lyon, France
- Laboratoire Biostatistique Santé, UCBL, Equipe de l'UMR CNRS 5558, 69495 Pierre-Bénite Cedex, France
| | - Nassima Yahiaoui
- Centre Régional de Pharmacovigilance, Pôle Santé Publique, Centre Hospitalier Universitaire de Grenoble, 38000 Grenoble, France
| | - Sébastien Chanoine
- Pôle Pharmacie, Centre Hospitalier Universitaire de Grenoble, 38000 Grenoble, France
- Université Grenoble Alpes, 38000 Grenoble, France
| | - Céline Villier
- Centre Régional de Pharmacovigilance, Pôle Santé Publique, Centre Hospitalier Universitaire de Grenoble, 38000 Grenoble, France
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103
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Abstract
Metabolic acidosis could emerge from diseases disrupting acid-base equilibrium or from drugs that induce similar derangements. Occurrences are usually accompanied by comorbid conditions of drug-induced metabolic acidosis, and clinical outcomes may range from mild to fatal. It is imperative that clinicians not only are fully aware of the list of drugs that may lead to metabolic acidosis but also understand the underlying pathogenic mechanisms. In this review, we categorized drug-induced metabolic acidosis in terms of pathophysiological mechanisms, as well as individual drugs’ characteristics.
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Affiliation(s)
- Amy Quynh Trang Pham
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Baylor Family Medicine Residency at Garland, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Li Hao Richie Xu
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Department of Physiology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
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104
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Shih CJ, Wu YL, Chao PW, Kuo SC, Yang CY, Li SY, Ou SM, Chen YT. Association between Use of Oral Anti-Diabetic Drugs and the Risk of Sepsis: A Nested Case-Control Study. Sci Rep 2015; 5:15260. [PMID: 26463557 PMCID: PMC4604480 DOI: 10.1038/srep15260] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/21/2015] [Indexed: 12/28/2022] Open
Abstract
Although oral antidiabetic drugs (OADs) have been associated with immunomodulation in preclinical studies, little is still known about the association between the use of OADs and the risk of sepsis. Using a cohort of patients, extracted from Taiwan's National Health Insurance Research Database, with type 2 diabetes who were newly diagnosed between 2010 and 2012 and treated with OADs, we conducted a nested case-control study involving 43,015 cases (patients who were first hospitalized for sepsis) and 43,015 matched controls. Compared with non-use, metformin use was associated with a decreased risk of developing sepsis (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.77-0.83, P < 0.001), but meglitinide (adjusted OR 1.32, 95% CI 1.25-1.40, P < 0.001) use was associated with the increased risk of developing sepsis. The risk for development of sepsis was also lower among current (adjusted OR 0.87, 95% CI 0.78-0.96) and recent (adjusted OR 0.83, 95% CI 0.73-0.94) thiazolidinedione users. Current or recent sulfonylurea use and dipeptidyl peptidase-4 inhibitor use were not significantly associated with the development of sepsis. Our results highlight the need to consider the potential pleiotropic effect of OADs against sepsis in addition to the lowering of blood glucose.
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Affiliation(s)
- Chia-Jen Shih
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Medicine, Taipei Veterans General Hospital, Yuanshan Branch, Yilan, Taiwan
| | - Yueh-Lin Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Taipei City Hospital, Zhongxiao Branch Branch, Taipei, Taiwan
| | - Pei-Wen Chao
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shu-Chen Kuo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli County, Taiwan
- Division of Infectious Diseases, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Yu Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Szu-Yuan Li
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shuo-Ming Ou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Tai Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Taipei City Hospital, Heping Fuyou Branch, Taipei, Taiwan
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105
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Christiansen CF, Ehrenstein V, Heide-Jørgensen U, Skovbo S, Nørrelund H, Sørensen HT, Li L, Jick S. Metformin initiation and renal impairment: a cohort study in Denmark and the UK. BMJ Open 2015; 5:e008531. [PMID: 26338686 PMCID: PMC4563232 DOI: 10.1136/bmjopen-2015-008531] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 08/06/2015] [Accepted: 08/12/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To estimate prevalence of renal impairment, rate of decline in kidney function and changes in metformin use after decline in kidney function, in metformin initiators. DESIGN, SETTING AND PARTICIPANTS We conducted this 2-country cohort study using routine data from northern Denmark and the UK during 2000-2011. We included metformin initiators among patients aged ≥30 years with medically treated diabetes. MAIN OUTCOME MEASURES We described patients' demographics, comorbidity, co-medications and their estimated glomerular filtration rates (eGFR). Furthermore, we described the patients' characteristics according to eGFR level. Finally, we examined the rate of any decline in eGFR and changes in metformin use within 90 days after first decline in eGFR during follow-up. RESULTS We included 124,720 metformin initiators in the 2 countries. Prevalence of eGFR <60 mL/min/1.73 m(2) among metformin initiators was 9.0% in Denmark and 25.2% in the UK. In contrast, prevalence of eGFR values <30 mL/min/1.73 m(2) among metformin initiators was 0.3% in Denmark and 0.4% in the UK. Patients with renal impairment were older and more likely to have received cardiovascular drugs. Incidence rate of decline in renal function was 4.92 per 100 person-years (95% CI 4.76 to 5.09) in Denmark and 7.48 per 100 person-years (95% CI 7.39 to 7.57) in the UK. The proportion of patients continuing metformin use, even after a first decline brought the eGFR below 30 mL/min/1.73 m(2), was 44% in Denmark and 62% in the UK. There was no clinically significant dose reduction with decreasing baseline eGFR level discernible from the data. CONCLUSIONS Mild to moderate renal impairment was common among metformin initiators, while severe renal impairment was uncommon. Patients with severe renal impairment frequently continued receiving/redeeming metformin prescriptions even 90 days after eGFR decline.
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Affiliation(s)
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Stine Skovbo
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Helene Nørrelund
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Lin Li
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, Massachusetts, USA
| | - Susan Jick
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, Massachusetts, USA
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106
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107
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Abstract
Lactic acidosis occurs when lactate production exceeds its metabolism. There are many possible causes of lactic acidosis, and in any given patient, several causes may coexist. This Attending Rounds presents a case in point. Metformin's role in the pathogenesis of lactic acidosis in patients with diabetes mellitus is complex, as the present case illustrates. The treatment of lactic acidosis is controversial, except for the imperative to remedy its underlying cause. The use of sodium bicarbonate to treat the often alarming metabolic derangements may be quite efficacious in that regard but is of questionable benefit to patients. Renal replacement therapies (RRTs) have particular appeal in this setting for a variety of reasons, but their effect on clinical outcomes is untested.
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Affiliation(s)
- Lawrence S Weisberg
- Division of Nephrology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
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108
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Hahr AJ, Molitch ME. Management of diabetes mellitus in patients with chronic kidney disease. Clin Diabetes Endocrinol 2015; 1:2. [PMID: 28702221 PMCID: PMC5469199 DOI: 10.1186/s40842-015-0001-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/03/2015] [Indexed: 12/11/2022] Open
Abstract
Glycemic control is essential to delay or prevent the onset of diabetic kidney disease. There are a number of glucose-lowering medications available but only a fraction of them can be used safely in chronic kidney disease and many of them need an adjustment in dosing. The ideal target hemoglobin A1c is approximately 7 % but this target is adjusted based on the needs of the patient. Diabetes control should be optimized for each individual patient, with measures to reduce diabetes-related complications and minimize adverse events. Overall care of diabetes necessitates attention to multiple aspects, including reducing the risk of cardiovascular disease, and often, multidisciplinary care is needed.
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Affiliation(s)
- Allison J. Hahr
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, 60611 Chicago, Illinois USA
| | - Mark E. Molitch
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, 60611 Chicago, Illinois USA
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109
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Selph S, Dana T, Blazina I, Bougatsos C, Patel H, Chou R. Screening for type 2 diabetes mellitus: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2015; 162:765-76. [PMID: 25867111 DOI: 10.7326/m14-2221] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Screening for type 2 diabetes mellitus could lead to earlier identification and treatment of asymptomatic diabetes, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT), potentially resulting in improved outcomes. PURPOSE To update the 2008 U.S. Preventive Services Task Force review on diabetes screening in adults. DATA SOURCES Cochrane databases and MEDLINE (2007 through October 2014) and relevant studies from previous Task Force reviews. STUDY SELECTION Randomized, controlled trials; controlled, observational studies; and systematic reviews. DATA EXTRACTION Data were abstracted by 1 investigator and checked by a second; 2 investigators independently assessed study quality. DATA SYNTHESIS In 2 trials, screening for diabetes was associated with no 10-year mortality benefit versus no screening (hazard ratio, 1.06 [95% CI, 0.90 to 1.25]). Sixteen trials consistently found that treatment of IFG or IGT was associated with delayed progression to diabetes. Most trials of treatment of IFG or IGT found no effects on all-cause or cardiovascular mortality, although lifestyle modification was associated with decreased risk for both outcomes after 23 years in 1 trial. For screen-detected diabetes, 1 trial found no effect of an intensive multifactorial intervention on risk for all-cause or cardiovascular mortality versus standard control. In diabetes that was not specifically screen-detected, 9 systematic reviews found that intensive glucose control did not reduce risk for all-cause or cardiovascular mortality and results for intensive blood pressure control were inconsistent. LIMITATION The review was restricted to English-language articles, and few studies were conducted in screen-detected populations. CONCLUSION Screening for diabetes did not improve mortality rates after 10 years of follow-up. More evidence is needed to determine the effectiveness of treatments for screen-detected diabetes. Treatment of IFG or IGT was associated with delayed progression to diabetes. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Shelley Selph
- From Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon
| | - Tracy Dana
- From Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon
| | - Ian Blazina
- From Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon
| | - Christina Bougatsos
- From Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon
| | - Hetal Patel
- From Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon
| | - Roger Chou
- From Pacific Northwest Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon
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110
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Zheng J, Woo SL, Hu X, Botchlett R, Chen L, Huo Y, Wu C. Metformin and metabolic diseases: a focus on hepatic aspects. Front Med 2015; 9:173-86. [PMID: 25676019 PMCID: PMC4567274 DOI: 10.1007/s11684-015-0384-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/24/2014] [Indexed: 12/25/2022]
Abstract
Metformin has been widely used as a first-line anti-diabetic medicine for the treatment of type 2 diabetes (T2D). As a drug that primarily targets the liver, metformin suppresses hepatic glucose production (HGP), serving as the main mechanism by which metformin improves hyperglycemia of T2D. Biochemically, metformin suppresses gluconeogenesis and stimulates glycolysis. Metformin also inhibits glycogenolysis, which is a pathway that critically contributes to elevated HGP. While generating beneficial effects on hyperglycemia, metformin also improves insulin resistance and corrects dyslipidemia in patients with T2D. These beneficial effects of metformin implicate a role for metformin in managing non-alcoholic fatty liver disease. As supported by the results from both human and animal studies, metformin improves hepatic steatosis and suppresses liver inflammation. Mechanistically, the beneficial effects of metformin on hepatic aspects are mediated through both adenosine monophosphate-activated protein kinase (AMPK)-dependent and AMPK-independent pathways. In addition, metformin is generally safe and may also benefit patients with other chronic liver diseases.
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Affiliation(s)
- Juan Zheng
- Department of Nutrition and Food Science, Texas A&M University, College Station, TX 77843, USA
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Shih-Lung Woo
- Department of Nutrition and Food Science, Texas A&M University, College Station, TX 77843, USA
| | - Xiang Hu
- Department of Nutrition and Food Science, Texas A&M University, College Station, TX 77843, USA
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Rachel Botchlett
- Department of Nutrition and Food Science, Texas A&M University, College Station, TX 77843, USA
| | - Lulu Chen
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuqing Huo
- Drug Discovery Center, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Chaodong Wu
- Department of Nutrition and Food Science, Texas A&M University, College Station, TX 77843, USA
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111
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Andrade JF, Silva V, Melnik T. Mulberry therapy for type 2 diabetes mellitus. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Janaina F Andrade
- Federal University of São Paulo (UNIFESP); Department of Evidence-Based Health; São Paulo Brazil
| | - Valter Silva
- Federal University of São Paulo (UNIFESP); Department of Evidence-Based Health; São Paulo Brazil
| | - Tamara Melnik
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; Federal University of Sao Paulo (Unifesp) Martiniano de Carvalho Street, 864/ cj 302 São Paulo São Paulo Brazil 01321-000
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112
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[Metformin-induced lactic acidosis : Severe symptoms with difficult diagnostics]. Anaesthesist 2015; 64:292-7. [PMID: 25870002 DOI: 10.1007/s00101-015-0017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 03/01/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
Metformin-induced lactic acidosis is a rare but severe disease for the individual patients. A case of a 64-year-old patient with diabetes mellitus type 2 suffering from this disease is presented where metformin accumulation was caused by prerenal acute kidney failure. The clinical evaluation up to the final diagnosis, the pathophysiology and the appropriate therapy are presented in detail. Additionally, the current guidelines regarding the perioperative management of metformin administration are summarized. The case described aims to direct attention to the rare but, nevertheless, severe symptoms of metformin-induced lactic acidosis.
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113
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Wallace IR, Waters NH, Pilmore H, Drury PL, Wu F. New onset diabetes after transplantation: Not another acronym! JRSM Open 2015; 6:2054270414567166. [PMID: 25780593 PMCID: PMC4349758 DOI: 10.1177/2054270414567166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
New onset diabetes after transplantation is the onset of diabetes in previously non-diabetic individuals extending beyond the first month post-transplantation.
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Affiliation(s)
- I R Wallace
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
| | - N H Waters
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
| | - H Pilmore
- Department of Transplant Nephrology, Auckland City Hospital, Auckland 1023, New Zealand
| | - P L Drury
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
| | - F Wu
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland 1051, New Zealand
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114
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Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR. Management of hyperglycaemia in type 2 diabetes, 2015: a patient-centred approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2015; 58:429-42. [PMID: 25583541 DOI: 10.1007/s00125-014-3460-0] [Citation(s) in RCA: 494] [Impact Index Per Article: 54.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 10/20/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT, USA
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115
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Kaiser D, Oetjen E. Something old, something new and something very old: drugs for treating type 2 diabetes. Br J Pharmacol 2015; 171:2940-50. [PMID: 24641580 DOI: 10.1111/bph.12624] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/13/2014] [Accepted: 01/30/2014] [Indexed: 12/28/2022] Open
Abstract
Diabetes mellitus belongs to the most rapidly increasing diseases worldwide. Approximately 90-95% of these patients suffer from type 2 diabetes mellitus, which is characterized by peripheral insulin resistance and the progressive loss of beta-cell function and mass. Considering the complications of this chronic disease, a reliable anti-diabetic treatment is indispensable. An ideal oral anti-diabetic drug should not only correct glucose homeostasis but also preserve or even augment beta-cell function and mass, ameliorate the subclinical inflammation present under insulin-resistant conditions and prevent the macro- and microvascular consequences of diabetes in order to reduce the mortality. Despite the many anti-diabetic drugs already in use, there is an ongoing research for additional drugs, guided by different concepts of the pathogenesis of type 2 diabetes. This review will briefly summarize current oral anti-diabetic drugs. In addition, emerging strategies for the treatment of diabetes will be described, among them the inhibition of glucagon action and anti-inflammatory drugs. Their suitability as 'ideal anti-diabetic drugs' will be discussed.
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Affiliation(s)
- D Kaiser
- Department of Clinical Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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116
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Wiernsperger N. Metformin as a cellular protector; a synoptic view of modern evidences. J Nephropharmacol 2015; 4:31-36. [PMID: 28197472 PMCID: PMC5297476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 12/02/2014] [Indexed: 11/18/2022] Open
Abstract
Due to limited knowledge and chemical class effect assimilation the biguanide metformin has long been considered as a useful but risky treatment for type 2 diabetes treatment. The worldwide long-term experience of clinical use of this compound and the growing knowledge about its mechanisms of action have, however, reversed this reputation to the point that nowadays it is not only considered as relatively harmless but even increasingly as a cellular protector. The present mini-review simply aims at giving a brief overview of the evidences accumulated overt recent periods and to provide the reader with information as to mechanistic hypotheses, knowing that there remains a lot to be done to better understand the pleiotropic behavior of this drug and its possible future new therapeutic applications. Data are shown at a glance for the kidney but also for other various organs and cell types corroborating this new notion for an old drug and paradox.
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Affiliation(s)
- Nicolas Wiernsperger
- INSERM U1060, CarMeN Laboratory, INSA Lyon, Claude Bernard University, Villeurbanne, France
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117
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Inzucchi SE, Lipska KJ, Mayo H, Bailey CJ, McGuire DK. Metformin in patients with type 2 diabetes and kidney disease: a systematic review. JAMA 2014; 312:2668-75. [PMID: 25536258 PMCID: PMC4427053 DOI: 10.1001/jama.2014.15298] [Citation(s) in RCA: 383] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Metformin is widely viewed as the best initial pharmacological option to lower glucose concentrations in patients with type 2 diabetes mellitus. However, the drug is contraindicated in many individuals with impaired kidney function because of concerns of lactic acidosis. OBJECTIVE To assess the risk of lactic acidosis associated with metformin use in individuals with impaired kidney function. EVIDENCE ACQUISITION In July 2014, we searched the MEDLINE and Cochrane databases for English-language articles pertaining to metformin, kidney disease, and lactic acidosis in humans between 1950 and June 2014. We excluded reviews, letters, editorials, case reports, small case series, and manuscripts that did not directly pertain to the topic area or that met other exclusion criteria. Of an original 818 articles, 65 were included in this review, including pharmacokinetic/metabolic studies, large case series, retrospective studies, meta-analyses, and a clinical trial. RESULTS Although metformin is renally cleared, drug levels generally remain within the therapeutic range and lactate concentrations are not substantially increased when used in patients with mild to moderate chronic kidney disease (estimated glomerular filtration rates, 30-60 mL/min per 1.73 m2). The overall incidence of lactic acidosis in metformin users varies across studies from approximately 3 per 100,000 person-years to 10 per 100,000 person-years and is generally indistinguishable from the background rate in the overall population with diabetes. Data suggesting an increased risk of lactic acidosis in metformin-treated patients with chronic kidney disease are limited, and no randomized controlled trials have been conducted to test the safety of metformin in patients with significantly impaired kidney function. Population-based studies demonstrate that metformin may be prescribed counter to prevailing guidelines suggesting a renal risk in up to 1 in 4 patients with type 2 diabetes mellitus--use which, in most reports, has not been associated with increased rates of lactic acidosis. Observational studies suggest a potential benefit from metformin on macrovascular outcomes, even in patients with prevalent renal contraindications for its use. CONCLUSIONS AND RELEVANCE Available evidence supports cautious expansion of metformin use in patients with mild to moderate chronic kidney disease, as defined by estimated glomerular filtration rate, with appropriate dosage reductions and careful follow-up of kidney function.
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Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Kasia J Lipska
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Helen Mayo
- Health Sciences Digital Library and Learning Center, University of Texas Southwestern Medical Center, Dallas
| | - Clifford J Bailey
- School of Life & Health Sciences, Aston University, Birmingham, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
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Abstract
The number of available options for type 2 diabetes has increased steadily over the last decade. These include the insulins, metformin, sulfonylureas, thiazolidinediones, incretin-based therapies, and sodium-glucose cotransporter 2 inhibitors. In this paper, the safety and efficacy of these agents are reviewed with a view on updated findings that have emerged over the last few years. Most drugs for type 2 diabetes effectively lower glycated hemoglobin. Their efficacy is in the range of approximate 0.8-1.5 % reduction in glycated hemoglobin for most agents. No drug for type 2 diabetes has been shown to reduce cardiovascular risk in a clinical trial which represents a gap in the therapeutic armamentarium for type 2 diabetes. Recent evidence has linked the thiazolidinediones to bladder cancer and raised concerns about pancreatic cancer with incretins, which requires further confirmation. The rapidly emerging evidence in the field of pharmacoepidemiology of diabetes will continue to provide answers to important questions on safety and efficacy in 2015 and beyond.
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Affiliation(s)
- Sonal Singh
- Johns Hopkins University School of Medicine, E7144, 624 N Wolfe St, Baltimore, MD, 21287, USA,
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119
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Sparkes ST, Patel DK, Goldman-Levine JD. Past, Present, and Future Research Avenues for Metformin: A Literature Review. J Pharm Technol 2014; 30:227-234. [PMID: 34860874 PMCID: PMC5990160 DOI: 10.1177/8755122514544527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2024] Open
Abstract
Objective: To review why metformin is considered first-line therapy for type 2 diabetes mellitus (T2DM) and review newer avenues of research currently being evaluated. Data Sources: The Cochrane Library and Medline (to January 2014) were searched for case-control and cohort studies, clinical trials, and systematic reviews and meta-analyses involving metformin for any indication. Study Selection and Data Extraction: The literature search found 5 major avenues of research for metformin: reduction in mortality, delayed-onset or prevention of T2DM in the presence of prediabetes, nonalcoholic fatty liver disease (NAFLD), polycystic ovarian syndrome (PCOS), and decreased cancer risk. When available, multi-center, double-blind, controlled clinical trials or meta-analyses thereof were selected for review. If these types of studies did not exist, other types of studies were chosen for review. Data Synthesis: Metformin significantly decreases all-cause and diabetes-related mortality in overweight and obese patients with T2DM. It may also decrease risk of progression to T2DM in patients with prediabetes. Metformin has been studied for the treatment of NAFLD though data are limited. Metformin alone or combined with clomiphene may increase pregnancy and ovulation rates but has not yet been shown to increase live-birth rates in patients with PCOS. Metformin may decrease risk of colorectal cancer but not all-cancer risk. Conclusions: Metformin's clinical role in T2DM and prediabetes is well established. Other avenues of research being evaluated at this time are NAFLD, PCOS, and reduced risk of cancer; more data are needed before it has a clinical role in these indications.
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120
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Du YF, Ou HY, Beverly EA, Chiu CJ. Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options. Clin Interv Aging 2014; 9:1963-80. [PMID: 25429208 PMCID: PMC4241951 DOI: 10.2147/cia.s53482] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population.
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Affiliation(s)
- Ye-Fong Du
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Horng-Yih Ou
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Elizabeth A Beverly
- Department of Social Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Ching-Ju Chiu
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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121
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Triggle CR, Ding H. Cardiovascular impact of drugs used in the treatment of diabetes. Ther Adv Chronic Dis 2014; 5:245-68. [PMID: 25364492 PMCID: PMC4205571 DOI: 10.1177/2040622314546125] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The International Diabetes Federation predicts that by 2035 10% of the population of the world will have been diagnosed with diabetes, raising serious concerns over the resulting elevated morbidity and mortality as well as the impact on health care budgets. It is also well recognized that cardiovascular disease is the primary cause of the high morbidity and mortality associated with diabetes, raising the concern that appropriate drug therapy should not only correct metabolic dysfunction, but also protect the cardiovascular system from the effects of, in particular, the epigenetic changes that result from hyperglycaemia. A number of new classes of drugs for the treatment of diabetes have been introduced in the past decade, providing the opportunity to optimize treatment; however, comparative information of the cardiovascular benefits, or risks, of the newer drugs versus older therapies such as metformin is variable. This review, in addition to summarizing the cellular basis for the therapeutic action of these drugs, addresses the evidence for their cardiovascular benefits and risks. A particular focus is provided on metformin as it is the first choice drug for most patients with type 2 diabetes.
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Affiliation(s)
- Chris R Triggle
- Departments of Pharmacology and Medical Education, Weill Cornell Medical College in Qatar, PO Box 24144, Education City, Doha, Qatar
| | - Hong Ding
- Departments of Pharmacology and Medical Education, Weill Cornell Medical College in Qatar, Education City, Doha, Qatar
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122
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Tuttle KR, Bakris GL, Bilous RW, Chiang JL, de Boer IH, Goldstein-Fuchs J, Hirsch IB, Kalantar-Zadeh K, Narva AS, Navaneethan SD, Neumiller JJ, Patel UD, Ratner RE, Whaley-Connell AT, Molitch ME. Diabetic kidney disease: a report from an ADA Consensus Conference. Diabetes Care 2014; 37:2864-83. [PMID: 25249672 PMCID: PMC4170131 DOI: 10.2337/dc14-1296] [Citation(s) in RCA: 703] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The incidence and prevalence of diabetes mellitus have grown significantly throughout the world, due primarily to the increase in type 2 diabetes. This overall increase in the number of people with diabetes has had a major impact on development of diabetic kidney disease (DKD), one of the most frequent complications of both types of diabetes. DKD is the leading cause of end-stage renal disease (ESRD), accounting for approximately 50% of cases in the developed world. Although incidence rates for ESRD attributable to DKD have recently stabilized, these rates continue to rise in high-risk groups such as middle-aged African Americans, Native Americans, and Hispanics. The costs of care for people with DKD are extraordinarily high. In the Medicare population alone, DKD-related expenditures among this mostly older group were nearly $25 billion in 2011. Due to the high human and societal costs, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation to appraise issues regarding patient management, highlighting current practices and new directions. Major topic areas in DKD included 1) identification and monitoring, 2) cardiovascular disease and management of dyslipidemia, 3) hypertension and use of renin-angiotensin-aldosterone system blockade and mineralocorticoid receptor blockade, 4) glycemia measurement, hypoglycemia, and drug therapies, 5) nutrition and general care in advanced-stage chronic kidney disease, 6) children and adolescents, and 7) multidisciplinary approaches and medical home models for health care delivery. This current state summary and research recommendations are designed to guide advances in care and the generation of new knowledge that will meaningfully improve life for people with DKD.
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Affiliation(s)
- Katherine R Tuttle
- University of Washington School of Medicine, Seattle, WA, and Providence Health Care, Spokane, WA
| | - George L Bakris
- Comprehensive Hypertension Center, The University of Chicago Medicine, Chicago, IL (National Kidney Foundation liaison)
| | | | | | - Ian H de Boer
- Division of Nephrology, University of Washington, Seattle, WA
| | | | - Irl B Hirsch
- Division of Metabolism, Endocrinology and Nutrition, University of Washington School of Medicine, Seattle, WA
| | | | - Andrew S Narva
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Sankar D Navaneethan
- Department of Nephrology and Hypertension, Novick Center for Clinical and Translational Research, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Joshua J Neumiller
- Department of Pharmacotherapy, College of Pharmacy, Washington State University, Spokane, WA
| | - Uptal D Patel
- Divisions of Nephrology and Pediatric Nephrology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (American Society of Nephrology liaison)
| | | | - Adam T Whaley-Connell
- Harry S. Truman Memorial Veterans Hospital, Columbia, MO, and Department of Internal Medicine, Division of Nephrology and Hypertension, University of Missouri School of Medicine, Columbia, MO
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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123
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Abstract
Adverse drug events (ADEs) are an important public health concern, accounting for 5% of all hospital admissions and two-thirds of all complications occurring shortly after hospital discharge. There are often long delays between when a drug is approved and when serious ADEs are identified. Recent and ongoing advances in drug safety surveillance include the establishment of government-sponsored networks of population databases, the use of data mining approaches, and the formal integration of diverse sources of drug safety information. These advances promise to reduce delays in identifying drug-related risks and in providing reassurance about the absence of such risks.
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Affiliation(s)
- Sean Hennessy
- Center for Pharmacoepidemiology Research and Training; Center for Clinical Epidemiology and Biostatistics; Department of Biostatistics and Epidemiology; and Department of Pharmacology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104;
| | - Brian L. Strom
- Rutgers the State University of New Jersey, Newark, New Jersey 07103, and Center for Pharmacoepidemiology Research and Training; Center for Clinical Epidemiology and Biostatistics; and Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104;
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124
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Abstract
The prevalence of diabetes is rising in the >65 year-old group. The challenge of defining the goals of therapy arises from the heterogeneity of the aging process and the sparse clinical data in this patient population. In light of these challenges, the clinician should be aware of the pitfalls of caring for the older diabetic patient and prioritize an individualized treatment plan to ensure an optimal glycemic control, without placing the patient at unnecessary risk. We present a review of the current guidelines and literature that deal specifically with the treatment of the older diabetic patient in order to establish the principles of treatment in this age group and help the clinician make decisions regarding the care of these patients.
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Affiliation(s)
- Louise Kezerle
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Leah Shalev
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
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125
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Grün B, Kiessling MK, Burhenne J, Riedel KD, Weiss J, Rauch G, Haefeli WE, Czock D. Trimethoprim-metformin interaction and its genetic modulation by OCT2 and MATE1 transporters. Br J Clin Pharmacol 2014; 76:787-96. [PMID: 23305245 DOI: 10.1111/bcp.12079] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 12/22/2012] [Indexed: 12/11/2022] Open
Abstract
AIMS Metformin pharmacokinetics depends on the presence and activity of membrane-bound drug transporters and may be affected by transport inhibitors. The aim of this study was to investigate the effects of trimethoprim on metformin pharmacokinetics and genetic modulation by organic cation transporter 2 (OCT2) and multidrug and toxin extrusion 1 (MATE1) polymorphisms. METHODS Twenty-four healthy volunteers received metformin 500 mg three times daily for 10 days and trimethoprim 200 mg twice daily from day 5 to 10. Effects of trimethoprim on steady-state metformin pharmacokinetics were analysed. RESULTS In the population as a whole, trimethoprim significantly reduced the apparent systemic metformin clearance (CL/F) from 74 to 54 l h(-1) and renal metformin clearance from 31 to 21 l h(-1) , and prolonged half-life from 2.7 to 3.6 h (all P < 0.01). This resulted in an increase in the maximal plasma concentration by 38% and in the area under the plasma concentration-time curve by 37%. In volunteers polymorphic for both OCT2 and MATE1, trimethoprim had no relevant inhibitory effects on metformin kinetics. Trimethoprim was associated with a decrease in creatinine clearance from 133 to 106 ml min(-1) (P < 0.01) and an increase in plasma lactate from 0.94 to 1.2 mmol l(-1) (P = 0.016). CONCLUSIONS The extent of inhibition by trimethoprim was moderate, but might be clinically relevant in patients with borderline renal function or high-dose metformin.
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Affiliation(s)
- Barbara Grün
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
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126
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Huang DL, Abrass IB, Young BA. Medication safety and chronic kidney disease in older adults prescribed metformin: a cross-sectional analysis. BMC Nephrol 2014; 15:86. [PMID: 24906409 PMCID: PMC4057526 DOI: 10.1186/1471-2369-15-86] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 05/01/2014] [Indexed: 11/28/2022] Open
Abstract
Background Medication safety in patients with chronic kidney disease (CKD) is a growing concern. This is particularly relevant in older adults due to underlying CKD. Metformin use is contraindicated in patients with abnormal kidney function; however, many patients are potentially prescribed metformin inappropriately. We evaluated the prevalence of CKD among older adults prescribed metformin for type 2 diabetes mellitus using available equations to estimate kidney function and examined demographic characteristics of patients who were potentially inappropriately prescribed metformin. Methods We conducted a cross-sectional analysis of older adults aged ≥65 years prescribed metformin from March 2008-March 2009 at an urban tertiary-care facility in Seattle, Washington, USA. CKD was defined using National Kidney Foundation-Kidney Disease Outcomes Quality Initiative criteria. Creatinine clearance was calculated using the Cockcroft-Gault equation; estimated glomerular filtration rate was calculated using the abbreviated Modification of Diet in Renal Disease (MDRD) and CKD-Epidemiology (EPI) Collaboration equations. Regression analyses were used to determine the associations between demographic characteristics and prevalent CKD. Results Among 356 subjects (median age 69 years, 52.5% female, 39.4% non-Hispanic black), prevalence of stage 3 or greater CKD calculated by any of the equations was 31.4%. The Cockcroft-Gault equation identified more subjects as having CKD (23.7%) than the abbreviated MDRD (21.1%) or CKD-EPI (21.7%) equations (P < 0.001). Older age (OR = 1.13, 95% CI 1.08-1.19) and female sex (OR = 2.51, 95% CI 1.44-4.38) were associated with increased odds of potentially inappropriate metformin prescription due to CKD; non-Hispanic black race was associated with decreased odds of potentially inappropriate metformin prescription due to CKD (OR = 0.41, 95% CI 0.23-0.71). Conclusions CKD is common in older adults prescribed metformin for type 2 diabetes, raising concern for potentially inappropriate medication use. No single equation to estimate kidney function may accurately identify CKD in this population. Medication safety deserves greater consideration among elderly patients due to the widespread prevalence of CKD.
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Affiliation(s)
- Deborah L Huang
- Division of General Internal Medicine, University of Washington, Box 354765, 4245 Roosevelt Way NE, Seattle, WA 98105, USA.
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127
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Abstract
Metformin is the most commonly prescribed medication for type 2 diabetes (T2DM) in the world. It has primacy in the treatment of this disease because of its safety record and also because of evidence for reduction in the risk of cardiovascular events. Evidence has accumulated indicating that metformin is safe in people with stage 3 chronic kidney disease (CKD-3). It is estimated that roughly one-quarter of people with CKD-3 and T2DM in the United States (well over 1 million) are ineligible for metformin treatment because of elevated serum creatinine levels. This could be overcome if a scheme, perhaps based on pharmacokinetic studies, could be developed to prescribe reduced doses of metformin in these individuals. There is also substantial evidence from epidemiologic studies to indicate that metformin may not only be safe, but may actually benefit people with heart failure (HF). Prospective, randomized trials of the use of metformin in HF are needed to investigate this possibility.
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Affiliation(s)
- John M. Miles
- To whom correspondence should be addressed. Telephone 507 284 3289; Fax 507 255 4828
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128
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Ncomanzi D, Sicat RMR, Sundararajan K. Metformin-associated lactic acidosis presenting as an ischemic gut in a patient who then survived a cardiac arrest: a case report. J Med Case Rep 2014; 8:159. [PMID: 24884658 PMCID: PMC4035763 DOI: 10.1186/1752-1947-8-159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 04/28/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Lactic acidosis is the most common cause of metabolic acidosis in hospitalized patients. It is recognized as a potential complication of metformin use, particularly in patients with risk factors such as renal dysfunction, liver disease, and heavy alcohol ingestion. These conditions are associated with systemic hypoxemia, which may be caused by cardiorespiratory disease, major surgery, sepsis, dehydration, old age, and overdose. The reported frequency of lactic acidosis is 0.06 per 1000 patient-years, mostly in patients with predisposing factors. This case is important because it details the seriousness of metformin-associated lactic acidosis in a critically ill patient and because, to the best of our knowledge, our patient survived with minimal residual defect despite experiencing a cardiac arrest. CASE PRESENTATION A 66-year-old Caucasian woman presented to our hospital with profound lactic acidosis, which was initially thought to be ischemic gut. She then survived an in-hospital pulseless electrical activity arrest. CONCLUSION Metformin-associated lactic acidosis is a diagnosis by exclusion; however, a high degree of clinical suspicion supplemented by prompt multisystem organ support can significantly influence the outcome in critically ill patients.
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Affiliation(s)
| | | | - Krishnaswamy Sundararajan
- Intensive care unit, Critical care services, Level 4, Robert Gerard Wing, Royal Adelaide Hospital, North terrace, Adelaide, SA 5000, Australia.
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129
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Gionfriddo MR, Morey-Vargas OL, Brito JP, Leppin AL, Murad MH, Montori VM. Systematic reviews to ascertain the safety of diabetes medications. Curr Diab Rep 2014; 14:478. [PMID: 24563375 PMCID: PMC4002287 DOI: 10.1007/s11892-014-0478-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clinicians and patients with type 2 diabetes enjoy an expanding list of medications to improve glycemic control. With this expansion has come a flurry of concerns about the safety of these antihyperglycemic agents, concerns that affect judgments about the risk/benefit balance of therapy. Some of these safety signals have been identified through the synthesis of existing research evidence. Thus, it has become important for clinicians and clinical policymakers to understand the strengths and limitations of systematic reviews and meta-analyses in determining the safety of diabetes medications. In this paper, we highlight key safety concerns with diabetes medications and discuss the role evidence synthesis plays in each, with special attention to its strengths and limitations.
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Affiliation(s)
- Michael R. Gionfriddo
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Mayo Graduate School, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Oscar L. Morey-Vargas
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Aaron L. Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - M. Hassan Murad
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Division of Health Care Policy and Research, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Corresponding Author: Victor M. Montori M.D. Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel.: 1-507-293-0175; fax: 1-507-538-0850. (V.M. Montori)
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McCarty MF. AMPK activation--protean potential for boosting healthspan. AGE (DORDRECHT, NETHERLANDS) 2014; 36:641-663. [PMID: 24248330 PMCID: PMC4039279 DOI: 10.1007/s11357-013-9595-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/22/2013] [Indexed: 06/01/2023]
Abstract
AMP-activated kinase (AMPK) is activated when the cellular (AMP+ADP)/ATP ratio rises; it therefore serves as a detector of cellular "fuel deficiency." AMPK activation is suspected to mediate some of the health-protective effects of long-term calorie restriction. Several drugs and nutraceuticals which slightly and safely impede the efficiency of mitochondrial ATP generation-most notably metformin and berberine-can be employed as clinical AMPK activators and, hence, may have potential as calorie restriction mimetics for extending healthspan. Indeed, current evidence indicates that AMPK activators may reduce risk for atherosclerosis, heart attack, and stroke; help to prevent ventricular hypertrophy and manage congestive failure; ameliorate metabolic syndrome, reduce risk for type 2 diabetes, and aid glycemic control in diabetics; reduce risk for weight gain; decrease risk for a number of common cancers while improving prognosis in cancer therapy; decrease risk for dementia and possibly other neurodegenerative disorders; help to preserve the proper structure of bone and cartilage; and possibly aid in the prevention and control of autoimmunity. While metformin and berberine appear to have the greatest utility as clinical AMPK activators-as reflected by their efficacy in diabetes management-regular ingestion of vinegar, as well as moderate alcohol consumption, may also achieve a modest degree of health-protective AMPK activation. The activation of AMPK achievable with any of these measures may be potentiated by clinical doses of the drug salicylate, which can bind to AMPK and activate it allosterically.
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Affiliation(s)
- Mark F McCarty
- Catalytic Longevity, 7831 Rush Rose Dr., Apt. 316, Carlsbad, CA, 92009, USA,
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131
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Pfeiffer AFH, Klein HH. The treatment of type 2 diabetes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:69-81; quiz 82. [PMID: 24612534 PMCID: PMC3952010 DOI: 10.3238/arztebl.2014.0069] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 11/03/2013] [Accepted: 11/03/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND 5% to 8% of adults have type 2 diabetes, a disease that is usually asymptomatic at first. The goals of management are timely diagnosis and the prevention of complications. METHODS Selective review of the literature, including guidelines from Germany and abroad. RESULTS High caloric intake and lack of exercise are the main contributing causes of type 2 diabetes and the principal targets of intervention. If lifestyle changes do not yield adequate improvement, then drug treatment should be initiated (or intensified) and managed on the basis of the HbA1c fraction. Guidelines recommend an HbA1c target range of 6.5% to 7.5%; the individual target value should be chosen in consideration of patient-specific factors and established in collaboration with the patient. Metformin is recommended for initial drug treatment. If metformin is contraindicated, poorly tolerated, or inadequately effective, many therapeutic alternatives and supplements are available. Clinical trials have shown that sulfonylureas and insulin are beneficial with respect to patient-relevant endpoints, but comparable data from clinical trials are not yet available for any other antidiabetic drug (except metformin). For individual patients, other drugs may have advantages such as a lower risk of hypoglycemia, less weight gain, oral administration, and/or applicability in the setting of renal insufficiency. The treatment is individually oriented, depending on the patient's age, disease stage, body weight, comorbidities, work situation, adherence, and personal priorities. Combining more than two antidiabetic drugs is not recommended. CONCLUSION Although there are many treatment options, individualized long-term treatment still presents a challenge in many cases.
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Affiliation(s)
- Andreas F. H Pfeiffer
- German Institute of Human Nutrition (DIfE) Potsdam-Rehbrücke, Nuthetal
- Department of Endocrinology and Metabolic Diseases, Charité Campus Benjamin Franklin, Charité Universitätsmedizin Berlin
| | - Harald H Klein
- Medical Clinic I (General Internal Medicine, Endocrinology and Diabetology, Gastroenterology and Hepatology), Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Klinikum der Ruhr-Universität Bochum
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Groves EM, Yu K, Wong ND, Malik S. Standard and Novel Treatment Options for Metabolic Syndrome and Diabetes Mellitus. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:10.1007/s11936-013-0273-2. [PMID: 24234946 PMCID: PMC4022706 DOI: 10.1007/s11936-013-0273-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OPINION STATEMENT Type II diabetes and metabolic syndrome are 2 intertwined conditions that are critical to the healthcare landscape in the United States and abroad. Patients with either diabetes or metabolic syndrome can have a dramatically increased risk of developing cardiovascular disease. Numerous treatment options have existed for some time, which include nonpharmacologic and pharmacologic therapies. In addition, within the last decade, a multiple of novel treatment options have emerged for the management of hyperglycemia in particular. By targeting novel pathways beyond the secretion and supply of insulin, these new therapeutics provide a valuable adjunct to the currently available therapies for diabetes and metabolic syndrome. Here we discuss the current guideline-driven usage of standard therapies with some novel indications. In addition, we discuss the novel therapies for the treatment of hyperglycemia, their mechanisms of action, and appropriate therapeutic indications.
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Affiliation(s)
- Elliott M Groves
- Department of Internal Medicine, University of California Irvine
- Division of Cardiovascular Diseases, University of California Irvine
- Department of Biomedical Engineering, University of California Irvine
| | - Katherine Yu
- Department of Internal Medicine, University of California Irvine
| | - Nathan D. Wong
- Department of Internal Medicine, University of California Irvine
- Division of Cardiovascular Diseases, University of California Irvine
| | - Shaista Malik
- Department of Internal Medicine, University of California Irvine
- Division of Cardiovascular Diseases, University of California Irvine
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133
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Andersen LW, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc 2013; 88:1127-40. [PMID: 24079682 PMCID: PMC3975915 DOI: 10.1016/j.mayocp.2013.06.012] [Citation(s) in RCA: 408] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 05/31/2013] [Accepted: 06/26/2013] [Indexed: 02/07/2023]
Abstract
Lactate levels are commonly evaluated in acutely ill patients. Although most often used in the context of evaluating shock, lactate levels can be elevated for many reasons. While tissue hypoperfusion may be the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate level elevation as the clinical and prognostic importance of an elevated lactate level varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The present review is based on a comprehensive PubMed search between the dates of January 1, 1960, to April 30, 2013, using the search term lactate or lactic acidosis combined with known associations, such as shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine, malignancy, liver, toxins, overdose, and medication. We provide an overview of the pathogenesis of lactate level elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical end point of resuscitation are discussed. The review ends with some general recommendations on the management of patients with elevated lactate levels.
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Affiliation(s)
- Lars W. Andersen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Julie Mackenhauer
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
| | - Jonathan C. Roberts
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Katherine M. Berg
- Department of Medicine, Division of Pulmonary Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michael N. Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Anesthesia Critical Care, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michael W. Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Medicine, Division of Pulmonary Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Rena G, Pearson ER, Sakamoto K. Molecular mechanism of action of metformin: old or new insights? Diabetologia 2013; 56:1898-906. [PMID: 23835523 PMCID: PMC3737434 DOI: 10.1007/s00125-013-2991-0] [Citation(s) in RCA: 317] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 06/13/2013] [Indexed: 12/24/2022]
Abstract
Metformin is the first-line drug treatment for type 2 diabetes. Globally, over 100 million patients are prescribed this drug annually. Metformin was discovered before the era of target-based drug discovery and its molecular mechanism of action remains an area of vigorous diabetes research. An improvement in our understanding of metformin's molecular targets is likely to enable target-based identification of second-generation drugs with similar properties, a development that has been impossible up to now. The notion that 5' AMP-activated protein kinase (AMPK) mediates the anti-hyperglycaemic action of metformin has recently been challenged by genetic loss-of-function studies, thrusting the AMPK-independent effects of the drug into the spotlight for the first time in more than a decade. Key AMPK-independent effects of the drug include the mitochondrial actions that have been known for many years and which are still thought to be the primary site of action of metformin. Coupled with recent evidence of AMPK-independent effects on the counter-regulatory hormone glucagon, new paradigms of AMPK-independent drug action are beginning to take shape. In this review we summarise the recent research developments on the molecular action of metformin.
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Affiliation(s)
- Graham Rena
- Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY UK
| | - Ewan R. Pearson
- Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY UK
| | - Kei Sakamoto
- Nestlé Institute of Health Sciences SA, Campus EPFL, Quartier de l’innovation, bâtiment G, 1015 Lausanne, Switzerland
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135
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The role of co-morbidity in the selection of antidiabetic pharmacotherapy in type-2 diabetes. Cardiovasc Diabetol 2013; 12:62. [PMID: 23574917 PMCID: PMC3664601 DOI: 10.1186/1475-2840-12-62] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 03/27/2013] [Indexed: 01/08/2023] Open
Abstract
Metformin is, if not contraindicated and if tolerated, usually preferred over other antidiabetic drugs for the first line treatment of type-2 diabetes. The particular decision on which antidiabetic agent to use is based on variables such as efficacy, cost, potential side effects, effects on weight, comorbidities, hypoglycemia, risk, and patient preferences. However, there is no guidance how to consider these in the selection of antidiabetic drug treatment. In this work, we aimed to summarize available evidence and tried to give pragmatic treatment recommendations from a clinical practice perspective. There are clear contraindications for some drugs in those with impaired renal and liver function and precautions in those with heart failure for the use of metformin (NYHA III-IV) and glitazones. On the other hand, GLP-1 analogs, DPP-4 inhibitors and acarbose are generally less critical and can be used in the majority of patients. We identified the following gaps with respect to the selection of antidiabetic drug treatment in patients with co-morbid disease conditions: 1) Guidelines fail to give advice on the use of specific antidiabetic drugs in patients with co-morbidity. 2) The literature is deficient in studies documenting antidiabetic drug use in patients with severely impaired renal function, diabetic retinopathy, cerebrovascular disease and systolic heart failure. 3) Further there are no specific data on patients with multiple of these co-morbid disease conditions. We postulate that differential use of antidiabetic drugs in patients with co-morbid disease constellations will help to reduce treatment related complications and might improve prognosis.
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136
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Lexis CPH, van der Horst ICC, Lipsic E, van der Harst P, van der Horst-Schrivers ANA, Wolffenbuttel BHR, de Boer RA, van Rossum AC, van Veldhuisen DJ, de Smet BJGL. Metformin in non-diabetic patients presenting with ST elevation myocardial infarction: rationale and design of the glycometabolic intervention as adjunct to primary percutaneous intervention in ST elevation myocardial infarction (GIPS)-III trial. Cardiovasc Drugs Ther 2013; 26:417-26. [PMID: 22968678 PMCID: PMC3464381 DOI: 10.1007/s10557-012-6413-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Left ventricular dysfunction and the development of heart failure is a frequent and serious complication of myocardial infarction. Recent animal experimental studies suggested that metformin treatment reduces myocardial injury and preserves cardiac function in non-diabetic rats after experimental myocardial infarction. We will study the efficacy of metformin with the aim to preserve left ventricular ejection fraction in non-diabetic patients presenting with ST elevation myocardial infarction (STEMI). Methods The Glycometabolic Intervention as adjunct to Primary percutaneous intervention in ST elevation myocardial infarction (GIPS)-III trial is a prospective, single center, double blind, randomized, placebo-controlled trial. Three-hundred-and-fifty patients, without diabetes, requiring primary percutaneous coronary intervention (PCI) for STEMI will be randomized to metformin 500 mg twice daily or placebo treatment and will undergo magnetic resonance imaging (MRI) after 4 months. Major exclusion criteria were prior myocardial infarction and severe renal dysfunction. The primary efficacy parameter is left ventricular ejection fraction 4 months after randomization. Secondary and tertiary efficacy parameters include major adverse cardiac events, new onset diabetes and glycometabolic parameters, and echocardiographic diastolic function. Safety parameters include renal function deterioration and lactic acidosis. Conclusions The GIPS-III trial will evaluate the efficacy of metformin treatment to preserve left ventricular ejection fraction in STEMI patients without diabetes.
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Affiliation(s)
- Chris P H Lexis
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, PO Box 30.001, Groningen, the Netherlands.
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Abstract
New onset diabetes mellitus after transplant (NODAT) refers to the development of diabetes post-transplant in previously non-diabetic patients and is associated with increased rates of acute transplant rejection, infection, late cardiovascular events, and decreased survival. NODAT is primarily due to the immunosuppressive drug regimen but the standard predisposing risk factors for diabetes also pertain. NODAT is diagnosed by the standard ADA criteria, once prednisone doses are less than 10 mg per day and in the absence of acute illness. Sulfonylureas, metformin, DPP-4 inhibitors, GLP-1 agonists, and insulin can be used in treatment, but when there is impaired kidney or hepatic function, special precautions are necessary. In addition, those drugs interacting with P450 enzymes require additional consideration because of possible interaction with immunosuppressive drug metabolism.
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Affiliation(s)
- Ashley Therasse
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, Chicago, IL 60611, USA
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Sherafat-Kazemzadeh R, Yanovski SZ, Yanovski JA. Pharmacotherapy for childhood obesity: present and future prospects. Int J Obes (Lond) 2013; 37:1-15. [PMID: 22929210 PMCID: PMC3522799 DOI: 10.1038/ijo.2012.144] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric obesity is a serious medical condition associated with significant comorbidities during childhood and adulthood. Lifestyle modifications are essential for treating children with obesity, yet many have insufficient response to improve health with behavioral approaches alone. This review summarizes the relatively sparse data on pharmacotherapy for pediatric obesity and presents information on obesity medications in development. Most previously studied medications demonstrated, at best, modest effects on body weight and obesity-related conditions. It is to be hoped that the future will bring new drugs targeting specific obesity phenotypes that will allow clinicians to use etiology-specific, and therefore more effective, anti-obesity therapies.
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Affiliation(s)
- Roya Sherafat-Kazemzadeh
- Section on Growth and Obesity, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Susan Z. Yanovski
- Section on Growth and Obesity, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
| | - Jack A. Yanovski
- Section on Growth and Obesity, Program in Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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139
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Abstract
Does metformin-associated lactic acidosis really exist? Despite an old controversy, there is no doubt about it. But do we understand what is going on? Laboratory findings raised several hypotheses explaining the pathophysiology of this disease. The main cause could be an inhibition of either gluconeogenesis or mitochondrial respiratory chain complex I. From bench to bedside, one hypothesis is now confirmed in humans. Metformin poisoning involves, at least partially, a mitochondrial dysfunction.
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Affiliation(s)
- Jean-Christophe Orban
- Service de Réanimation Médico-chirurgicale, Hôpital Saint-Roch, Centre Hospitalier Universitaire de Nice, 5 rue Pierre Dévoluy, 06006 Nice, France
- IRCAN, Faculté de Médecine, Université de Nice, Avenue de Valombrose, 06107 Nice, France
| | - Eric Fontaine
- INSERM, U1055, 2280 rue de la piscine, 38041 Grenoble, France
| | - Carole Ichai
- Service de Réanimation Médico-chirurgicale, Hôpital Saint-Roch, Centre Hospitalier Universitaire de Nice, 5 rue Pierre Dévoluy, 06006 Nice, France
- IRCAN, Faculté de Médecine, Université de Nice, Avenue de Valombrose, 06107 Nice, France
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140
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Protti A, Lecchi A, Fortunato F, Artoni A, Greppi N, Vecchio S, Fagiolari G, Moggio M, Comi GP, Mistraletti G, Lanticina B, Faraldi L, Gattinoni L. Metformin overdose causes platelet mitochondrial dysfunction in humans. Crit Care 2012; 16:R180. [PMID: 23034133 PMCID: PMC3682281 DOI: 10.1186/cc11663] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/10/2012] [Accepted: 08/31/2012] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION We have recently demonstrated that metformin intoxication causes mitochondrial dysfunction in several porcine tissues, including platelets. The aim of the present work was to clarify whether it also causes mitochondrial dysfunction (and secondary lactate overproduction) in human platelets, in vitro and ex vivo. METHODS Human platelets were incubated for 72 hours with saline or increasing doses of metformin (in vitro experiments). Lactate production, respiratory chain complex activities (spectrophotometry), mitochondrial membrane potential (flow-cytometry after staining with JC-1) and oxygen consumption (Clark-type electrode) were then measured. Platelets were also obtained from ten patients with lactic acidosis (arterial pH 6.97 ± 0.18 and lactate 16 ± 7 mmol/L) due to accidental metformin intoxication (serum drug level 32 ± 14 mg/L) and ten healthy volunteers of similar sex and age. Respiratory chain complex activities were measured as above (ex vivo experiments). RESULTS In vitro, metformin dose-dependently increased lactate production (P < 0.001), decreased respiratory chain complex I activity (P = 0.009), mitochondrial membrane potential (P = 0.003) and oxygen consumption (P < 0.001) of human platelets. Ex vivo, platelets taken from intoxicated patients had significantly lower complex I (P = 0.045) and complex IV (P < 0.001) activity compared to controls. CONCLUSIONS Depending on dose, metformin can cause mitochondrial dysfunction and lactate overproduction in human platelets in vitro and, possibly, in vivo. TRIAL REGISTRATION NCT 00942123.
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Affiliation(s)
- Alessandro Protti
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Anna Lecchi
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Francesco Fortunato
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Andrea Artoni
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Noemi Greppi
- Centro Trasfusionale e di Immunoematologia, Dipartimento di Medicina Rigenerativa, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Sarah Vecchio
- Centro Nazionale di Informazione Tossicologica - Centro Antiveleni, Fondazione IRCCS Salvatore Maugeri, via S. Maugeri 10/10A, 27100 Pavia, Italy
| | - Gigliola Fagiolari
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Maurizio Moggio
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Giacomo Pietro Comi
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Giovanni Mistraletti
- U.O. Anestesia e Rianimazione, A.O. San Paolo, Università degli Studi di Milano, via A. Di Rudiní 8, 20142 Milan, Italy
| | - Barbara Lanticina
- U.O. Rianimazione, A.O. San Carlo Borromeo, via Pio II 3, 20147 Milan, Italy
| | - Loredana Faraldi
- Servizio Anestesia e Rianimazione 1°, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
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Tsaknis G, Siempos II, Kopterides P, Maniatis NA, Magkou C, Kardara M, Panoutsou S, Kotanidou A, Roussos C, Armaganidis A. Metformin attenuates ventilator-induced lung injury. Crit Care 2012; 16:R134. [PMID: 22827994 PMCID: PMC3580719 DOI: 10.1186/cc11439] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/01/2012] [Accepted: 07/24/2012] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Diabetic patients may develop acute lung injury less often than non-diabetics; a fact that could be partially ascribed to the usage of antidiabetic drugs, including metformin. Metformin exhibits pleiotropic properties which make it potentially beneficial against lung injury. We hypothesized that pretreatment with metformin preserves alveolar capillary permeability and, thus, prevents ventilator-induced lung injury. METHODS Twenty-four rabbits were randomly assigned to pretreatment with metformin (250 mg/Kg body weight/day per os) or no medication for two days. Explanted lungs were perfused at constant flow rate (300 mL/min) and ventilated with injurious (peak airway pressure 23 cmH₂O, tidal volume ≈17 mL/Kg) or protective (peak airway pressure 11 cmH₂O, tidal volume ≈7 mL/Kg) settings for 1 hour. Alveolar capillary permeability was assessed by ultrafiltration coefficient, total protein concentration in bronchoalveolar lavage fluid (BALF) and angiotensin-converting enzyme (ACE) activity in BALF. RESULTS High-pressure ventilation of the ex-vivo lung preparation resulted in increased microvascular permeability, edema formation and microhemorrhage compared to protective ventilation. Compared to no medication, pretreatment with metformin was associated with a 2.9-fold reduction in ultrafiltration coefficient, a 2.5-fold reduction in pulmonary edema formation, lower protein concentration in BALF, lower ACE activity in BALF, and fewer histological lesions upon challenge of the lung preparation with injurious ventilation. In contrast, no differences regarding pulmonary artery pressure and BALF total cell number were noted. Administration of metformin did not impact on outcomes of lungs subjected to protective ventilation. CONCLUSIONS Pretreatment with metformin preserves alveolar capillary permeability and, thus, decreases the severity of ventilator-induced lung injury in this model.
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Affiliation(s)
- George Tsaknis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Ilias I Siempos
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Petros Kopterides
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Nikolaos A Maniatis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
| | - Christina Magkou
- Department of Histopathology, Evangelismos Hospital, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Matina Kardara
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Stefania Panoutsou
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Anastasia Kotanidou
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- First Department of Critical Care and Pulmonary Services, "Evangelismos" Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Charis Roussos
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- First Department of Critical Care and Pulmonary Services, "Evangelismos" Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
| | - Apostolos Armaganidis
- GP Livanos and M Simou Laboratories, Evangelismos Hospital, University of Athens-Medical School, Ipsilandou 45-47, Athens, 106 75, Greece
- Critical Care Department, Attikon Hospital, University of Athens-Medical School, Rimini 1, Haidari, Athens, 124 62, Greece
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Chan DK, Miskimins WK. Metformin and phenethyl isothiocyanate combined treatment in vitro is cytotoxic to ovarian cancer cultures. J Ovarian Res 2012; 5:19. [PMID: 22781119 PMCID: PMC3439343 DOI: 10.1186/1757-2215-5-19] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 06/04/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND High mortality rates in ovarian cancer are largely a result of resistance to currently used chemotherapies. Expanding therapies with a variety of drugs has the potential to reduce this high mortality rate. Metformin and phenethyl isothiocyanate (PEITC) are both potentially useful in ovarian cancer, and they are particularly attractive because of their safety. METHODS Cell proliferation of each drug and drug combination was evaluated by hemacytometry with Trypan blue exclusion or Sytox green staining for cell death. Levels of total and cleaved PARP were measured by Western blot. General cellular and mitochondrial reactive oxygen species were measured by flow cytometry and live cell confocal microscopy with the fluorescent dyes dihydroethidine and MitoSOX. RESULTS Individually, metformin and PEITC each show inhibition of cell growth in multiple ovarian cancer cell lines. Alone, PEITC was also able to induce apoptosis, whereas metformin was primarily growth inhibitory. Both total cellular and mitochondrial reactive oxygen species were increased when treated with either metformin or PEITC. The growth inhibitory effects of metformin were reversed by methyl succinate supplementation, suggesting complex I plays a role in metformin's anti-cancer mechanism. PEITC's anti-cancer effect was reversed by N-acetyl-cysteine supplementation, suggesting PEITC relies on reactive oxygen species generation to induce apoptosis. Metformin and PEITC together showed a synergistic effect on ovarian cancer cell lines, including the cisplatin resistant A2780cis. CONCLUSIONS Here we show that when used in combination, these drugs are effective in both slowing cancer cell growth and killing ovarian cancer cells in vitro. Furthermore, the combination of these drugs remains effective in cisplatin resistant cell lines. Novel combinations such as metformin and PEITC show promise in expanding ovarian cancer therapies and overcoming the high incidence of cisplatin resistant cancers.
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Affiliation(s)
- Daniel K Chan
- Cancer Biology Research Center, Sanford Research/USD, 2301 East 60th Street-North, Sioux Falls, SD, 57104, USA
| | - W Keith. Miskimins
- Cancer Biology Research Center, Sanford Research/USD, 2301 East 60th Street-North, Sioux Falls, SD, 57104, USA
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143
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Protti A, Fortunato F, Monti M, Vecchio S, Gatti S, Comi GP, De Giuseppe R, Gattinoni L. Metformin overdose, but not lactic acidosis per se, inhibits oxygen consumption in pigs. Crit Care 2012; 16:R75. [PMID: 22568883 PMCID: PMC3580617 DOI: 10.1186/cc11332] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/19/2012] [Accepted: 05/08/2012] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Hepatic mitochondrial dysfunction may play a critical role in the pathogenesis of metformin-induced lactic acidosis. However, patients with severe metformin intoxication may have a 30 to 60% decrease in their global oxygen consumption, as for generalized inhibition of mitochondrial respiration. We developed a pig model of severe metformin intoxication to validate this clinical finding and assess mitochondrial function in liver and other tissues. METHODS Twenty healthy pigs were sedated and mechanically ventilated. Ten were infused with a large dose of metformin (4 to 8 g) and five were not (sham controls). Five others were infused with lactic acid to clarify whether lactic acidosis per se diminishes global oxygen use. Arterial pH, lactatemia, global oxygen consumption (VO2) (metabolic module) and delivery (DO2) (cardiac output by thermodilution) were monitored for nine hours. Oxygen extraction was computed as VO2/DO2. Activities of the main components of the mitochondrial respiratory chain (complex I, II and III, and IV) were measured with spectrophotometry (and expressed relative to citrate synthase activity) in heart, kidney, liver, skeletal muscle and platelets taken at the end of the study. RESULTS Pigs infused with metformin (6 ± 2 g; final serum drug level 77 ± 45 mg/L) progressively developed lactic acidosis (final arterial pH 6.93 ± 0.24 and lactate 18 ± 7 mmol/L, P < 0.001 for both). Their VO2 declined over time (from 115 ± 34 to 71 ± 30 ml/min, P < 0.001) despite grossly preserved DO2 (from 269 ± 68 to 239 ± 51 ml/min, P = 0.58). Oxygen extraction accordingly fell from 43 ± 10 to 30 ± 10% (P = 0.008). None of these changes occurred in either sham controls or pigs infused with lactic acid (final arterial pH 6.86 ± 0.16 and lactate 22 ± 3 mmol/L). Metformin intoxication was associated with inhibition of complex I in the liver (P < 0.001), heart (P < 0.001), kidney (P = 0.003), skeletal muscle (P = 0.012) and platelets (P = 0.053). The activity of complex II and III diminished in the liver (P < 0.001), heart (P < 0.001) and kidney (P < 0.005) while that of complex IV declined in the heart (P < 0.001). CONCLUSIONS Metformin intoxication induces lactic acidosis, inhibits global oxygen consumption and causes mitochondrial dysfunction in liver and other tissues. Lactic acidosis per se does not decrease whole-body respiration.
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Affiliation(s)
- Alessandro Protti
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 35, Milano 20122, Italy
| | - Francesco Fortunato
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 35, Milano 20122, Italy
| | - Massimo Monti
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 35, Milano 20122, Italy
| | - Sarah Vecchio
- Centro Nazionale di Informazione Tossicologica - Centro Antiveleni, Fondazione IRCCS Salvatore Maugeri, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Stefano Gatti
- Centro di Ricerche Chirurgiche Precliniche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 35, Milano 20122, Italy
| | - Giacomo P Comi
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 35, Milano 20122, Italy
| | - Rachele De Giuseppe
- Fondazione Fratelli Confalonieri, Dipartimento di Scienze Mediche, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milano 20122, Italy
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via Francesco Sforza 35, Milano 20122, Italy
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Berstein LM. Metformin in obesity, cancer and aging: addressing controversies. Aging (Albany NY) 2012; 4:320-9. [PMID: 22589237 PMCID: PMC3384433 DOI: 10.18632/aging.100455] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 04/29/2012] [Indexed: 12/25/2022]
Abstract
Metformin, an oral anti-diabetic drug, is being considered increasingly for treatment and prevention of cancer, obesity as well as for the extension of healthy lifespan. Gradually accumulating discrepancies about its effect on cancer and obesity can be explained by the shortage of randomized clinical trials, differences between control groups (reference points), gender- and age-associated effects and pharmacogenetic factors. Studies of the potential antiaging effects of antidiabetic biguanides, such as metformin, are still experimental for obvious reasons and their results are currently ambiguous. Here we discuss whether the discrepancies in different studies are merely methodological or inherently related to individual differences in responsiveness to the drug.
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Affiliation(s)
- Lev M Berstein
- Laboratory of Oncoendocrinology, N.N.Petrov Research Institute of Oncology, St. Petersburg, Russia.
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145
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Metformin attenuates Alzheimer's disease-like neuropathology in obese, leptin-resistant mice. Pharmacol Biochem Behav 2012; 101:564-74. [PMID: 22425595 DOI: 10.1016/j.pbb.2012.03.002] [Citation(s) in RCA: 177] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 02/27/2012] [Accepted: 03/03/2012] [Indexed: 01/21/2023]
Abstract
Diabetes increases the risk of Alzheimer's disease (AD). The pathological hallmarks for AD brains are extracellular amyloid plaques formed by β-amyloid peptide (Aβ) and intracellular neurofibrillary tangles consisting of hyperphosphorylated tau protein. This study was designed to determine AD-like brain changes in mice modeling for type 2 diabetes. The effects of metformin on these changes also were studied. Seven-week old male db/db mice received intraperitoneal injection of 200 mg kg⁻¹ d⁻¹ metformin for 18 weeks. They were subjected to Barnes maze at an age of 21 weeks and fear conditioning at an age of 24 weeks to assess their cognitive functions. Hippocampus was harvested after these tests for biochemical evaluation. The db/db mice had more tau phosphorylated at S396 and total tau in their hippocampi than their non-diabetic control db+mice. Activated/phosphorylated c-jun N-terminal kinase (JNK), a tau kinase, was increased in the db/db mouse hippocampus. Metformin attenuated the increase of total tau, phospho-tau and activated JNK. The db/db mice had increased Aβ levels. Metformin attenuated the reduction of synaptophysin, a synaptic protein, in the db/db mouse hippocampus. Metformin did not attenuate the impairments of spatial learning and memory as well as long-term hyperglycemia in the db/db mice. Our results suggest that the db/db mice have multiple AD-like brain changes including impaired cognitive functions, increased phospho-tau and Aβ as well as decreased synaptic proteins. Activation of JNK may contribute to the increased phospho-tau in the db/db mice. Metformin attenuates AD-like biochemical changes in the brain of these mice.
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de León-Castañeda CD, Altagracia-Martínez M, Kravzov-Jinich J, Cárdenas-Elizalde MDR, Moreno-Bonett C, Martínez-Núñez JM. Cost-effectiveness study of oral hypoglycemic agents in the treatment of outpatients with type 2 diabetes attending a public primary care clinic in Mexico City. CLINICOECONOMICS AND OUTCOMES RESEARCH 2012; 4:57-65. [PMID: 22427724 PMCID: PMC3304331 DOI: 10.2147/ceor.s27826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Worldwide, diabetes mellitus presents a high burden for individuals and society. In Latin America, many people with diabetes have limited access to health care, which means that indirect costs may exceed direct health care cost. Diabetes is Mexico's leading cause of death. PURPOSE To evaluate the cost-effectiveness ratios of the most used oral hypoglycemic agents (OHA) in the treatment of outpatients with type 2 diabetes attending a public primary care clinic in Mexico City. DESIGN A cross-sectional and analytic study was conducted in Mexico City. METHODOLOGY Twenty-seven adult outpatients with type 2 diabetes who were treated either with metformin or glibenclamide were included. Acarbose was used as an alternative strategy. The study was carried out from the perspective of Mexican society. Direct medical and nonmedical costs as well as indirect costs were evaluated using a structured questionnaire. Efficacies of all drug treatments were evaluated retrospectively. A systematic search was conducted to select published randomized clinical trials based on predetermined inclusion criteria, and treatment success was defined as glycosylated hemoglobin factor ≤ 7%. Efficacy data of each drug and/or combination were analyzed using meta-analysis. The Monte Carlo Markov model was used. Quality-adjusted life-years (QALY) were used as the unit of effectiveness; incremental and sensitive analyses were performed and a 5% discount rate was calculated. A hypothetical cohort of 10,000 patients was modeled. RESULTS The odds ratios of the success of each drug treatment were obtained from the meta-analyses, and were the following: 5.82 (glibenclamide), 3.86 (metformin), 3.5 (acarbose), and 6.76 (metformin-glibenclamide). The cost-effectiveness ratios found were US$272.63/QALY (glibenclamide), US$296.48/QALY (metformin), and US$409.86/QALY (acarbose). Sensitivity analysis did not show changes for the most cost-effective therapy when the effectiveness probabilities or treatment costs were modified. CONCLUSION Glibenclamide is the most cost-effective treatment for the present study outpatient population diagnosed with type 2 diabetes in the early stages.
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Affiliation(s)
- Christian Díaz de León-Castañeda
- Department of Biological Systems and Health Care, Biological and Health Sciences Division, Universidad Autónoma Metropolitana-Xochimilco, Mexico DF, Mexico
| | - Marina Altagracia-Martínez
- Department of Biological Systems and Health Care, Biological and Health Sciences Division, Universidad Autónoma Metropolitana-Xochimilco, Mexico DF, Mexico
| | - Jaime Kravzov-Jinich
- Department of Biological Systems and Health Care, Biological and Health Sciences Division, Universidad Autónoma Metropolitana-Xochimilco, Mexico DF, Mexico
| | - Ma del Rosario Cárdenas-Elizalde
- Department of Biological Systems and Health Care, Biological and Health Sciences Division, Universidad Autónoma Metropolitana-Xochimilco, Mexico DF, Mexico
| | - Consuelo Moreno-Bonett
- Department of Biological Systems and Health Care, Biological and Health Sciences Division, Universidad Autónoma Metropolitana-Xochimilco, Mexico DF, Mexico
| | - Juan Manuel Martínez-Núñez
- Department of Biological Systems and Health Care, Biological and Health Sciences Division, Universidad Autónoma Metropolitana-Xochimilco, Mexico DF, Mexico
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Detournay B, Simon D, Guillausseau PJ, Joly D, Verges B, Attali C, Clement O, Briand Y, Delaitre O. Chronic kidney disease in type 2 diabetes patients in France: prevalence, influence of glycaemic control and implications for the pharmacological management of diabetes. DIABETES & METABOLISM 2012; 38:102-12. [PMID: 22252014 DOI: 10.1016/j.diabet.2011.11.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 11/25/2011] [Accepted: 11/25/2011] [Indexed: 12/21/2022]
Abstract
AIM Type 2 diabetes mellitus (T2DM) is often associated with chronic kidney disease. For this reason, this article reviews the relationship between treatment of T2DM and renal disease. METHOD The review presents the recent French data on the management of diabetes in patients with renal impairment, and discusses the implications of renal disease for the treatment of such patients. Prescribing data are presented for various antidiabetic treatments, and the use of the more commonly prescribed medications is discussed with reference to T2DM patients with renal disease. RESULTS In France, it is estimated that 4-5% of the general population has T2DM and that almost 40% of patients with end-stage renal failure have diabetes. Diabetes and renal disease are both risk factors for cardiovascular morbidity and mortality. Glycaemic control is pivotal in T2DM patients for minimizing the risk of vascular complications and hypoglycaemic episodes, particularly in patients with renal disease who also have a higher risk of hypoglycaemia. Whereas poorly controlled glycaemia increases the risk of renal disease and its progression, the risk is diminished in patients treated intensively for diabetes and in those who achieve stable glycaemic control. Intensive multitargeted treatment can also help to decrease cardiovascular morbidity and mortality, especially if started early in patients who have not yet developed macrovascular complications. CONCLUSION In recent years, considerable improvement has been observed in France regarding the follow-up of diabetic patients. Less extensive, but nonetheless significant, improvement has also been observed in glycaemic control. However, even though treatment decisions generally take renal function into account, some at-risk treatments are often still being used in patients with renal insufficiency.
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Affiliation(s)
- B Detournay
- Cemka-Eval, 43 boulevard du Maréchal-Joffre, Bourg-la-Reine, France.
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Ekström N, Schiöler L, Svensson AM, Eeg-Olofsson K, Miao Jonasson J, Zethelius B, Cederholm J, Eliasson B, Gudbjörnsdottir S. Effectiveness and safety of metformin in 51 675 patients with type 2 diabetes and different levels of renal function: a cohort study from the Swedish National Diabetes Register. BMJ Open 2012; 2:bmjopen-2012-001076. [PMID: 22798258 PMCID: PMC3400073 DOI: 10.1136/bmjopen-2012-001076] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of metformin use in clinical practice in a large sample of pharmacologically treated patients with type 2 diabetes and different levels of renal function. DESIGN Observational study between July 2004 and December 2010, mean follow-up 3.9 years. SETTING Hospital outpatient clinics and primary care in Sweden. PARTICIPANTS 51 675 men and women with type 2 diabetes, registered in the Swedish National Diabetes Register, and on continuous glucose-lowering treatment with oral hypoglycaemic agents (OHAs) or insulin. MAIN OUTCOME MEASURES Risks of cardiovascular disease (CVD), all-cause mortality and acidosis/serious infection, associated with each treatment regimens, were analysed in all patients and in subgroups with different estimated glomerular filtration rate (eGFR) intervals. Covariance adjustment and propensity scores were used to adjust for several baseline risk factors and characteristics at Cox regression. RESULTS Compared with metformin in monotherapy, HRs for fatal/non-fatal CVD and all-cause mortality with all other OHAs combined (approximately 80% sulphonylureas) in monotherapy were 1.02 (95% CI 0.93 to 1.12) and 1.13 (1.01 to 1.27), while 1.18 (1.07 to 1.29) and 1.34 (1.19 to 1.50) with insulin in monotherapy, adjusting using propensity scores. Metformin, compared with any other treatment, showed reduced risks of acidosis/serious infection (adjusted HR 0.85, 95% CI 0.74 to 0.97) and all-cause mortality (HR 0.87, 95% CI 0.77 to 0.99), in patients with eGFR 45-60 ml/min/1.73 m(2), and no increased risks of all-cause mortality, acidosis/serious infection or CVD were found in patients with eGFR 30-45 ml/min/1.73 m(2). CONCLUSIONS Metformin showed lower risk than insulin for CVD and all-cause mortality and slightly lower risk for all-cause mortality compared with other OHA, in these 51 675 patients followed for 4 years. Patients with renal impairment showed no increased risk of CVD, all-cause mortality or acidosis/serious infection. In clinical practice, the benefits of metformin use clearly outbalance the risk of severe side effects.
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Affiliation(s)
- Nils Ekström
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Linus Schiöler
- Centre of Registers in Region Västra Götaland, Gothenburg, Sweden
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Katarina Eeg-Olofsson
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Björn Zethelius
- Department of Public Health and Caring Science/Geriatrics, Uppsala University, Sweden
- Medical Products Agency, Uppsala, Sweden
| | - Jan Cederholm
- Department of Public Health and Caring Science/Family Medicine and Clinical Epidemiology, Uppsala University, Sweden
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers in Region Västra Götaland, Gothenburg, Sweden
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Okayasu S, Kitaichi K, Hori A, Suwa T, Horikawa Y, Yamamoto M, Takeda J, Itoh Y. The Evaluation of Risk Factors Associated with Adverse Drug Reactions by Metformin in Type 2 Diabetes Mellitus. Biol Pharm Bull 2012; 35:933-7. [DOI: 10.1248/bpb.35.933] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Shinji Okayasu
- Department of Pharmacy, Gifu University Hospital
- United Graduate School of Drug Discovery and Medical Information Sciences, Gifu University
| | | | - Akina Hori
- Department of Pharmacy, Gifu University Hospital
| | - Tetsuya Suwa
- Department of Diabetes and Endocrinology, Division of Molecule and Structure, School of Medicine, Gifu University
| | - Yukio Horikawa
- Department of Diabetes and Endocrinology, Division of Molecule and Structure, School of Medicine, Gifu University
| | - Mayumi Yamamoto
- United Graduate School of Drug Discovery and Medical Information Sciences, Gifu University
- Department of Diabetes and Endocrinology, Division of Molecule and Structure, School of Medicine, Gifu University
| | - Jun Takeda
- Department of Diabetes and Endocrinology, Division of Molecule and Structure, School of Medicine, Gifu University
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