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Silverii GA. Optimizing metformin therapy in practice: Tailoring therapy in specific patient groups to improve tolerability, efficacy and outcomes. Diabetes Obes Metab 2024; 26 Suppl 3:42-54. [PMID: 38987983 DOI: 10.1111/dom.15749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/05/2024] [Accepted: 06/14/2024] [Indexed: 07/12/2024]
Abstract
Metformin is the first-line medication for type 2 diabetes. It is effective and safe, provided some caution is taken in specific populations. In patients with chronic kidney disease, metformin may provide long-term benefits, and it is a first-line therapy for diabetes, but the estimated glomerular filtration rate (eGFR) must be assessed regularly, to minimize the risk for metformin accumulation. When eGFR is 30-60 mL/min/1.73m2, the dose should be reconsidered, and sick-days education provided. Metformin should be discontinued when eGFR falls below 30 mL/min/1.73m2. Metformin accumulation may increase the risk for lactic acidosis if concomitant risk factors for hyperlactataemia (liver or respiratory insufficiency, sepsis, acute heart failure) are present; in these conditions, metformin is contraindicated, even although the available evidence is reassuring. Patients on metformin often complain of gastrointestinal side effects (mainly diarrhoea and nausea) during therapy initiation, but they may sometimes occur after years of stable therapy. These usually resolve if the dose is carefully titrated, or by switching to the extended-release formulation. Patients with obesity may benefit from the significant, although modest, metformin-associated weight loss and appetite reduction. During pregnancy, metformin is associated with a reduction of pregnancy complications, especially in obese women, but some concern remains, because metformin crosses the placenta, and it is associated with a significantly lower mean birth weight than insulin. In the elderly, gastrointestinal tolerability and renal function must be reassessed more often. Vitamin B-12 should be screened regularly in long-time metformin users because metformin may induce clinical vitamin B-12 deficiency.
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Affiliation(s)
- Giovanni Antonio Silverii
- Experimental and Clinical Biomedical Sciences "Mario Serio" Department, University of Florence, Florence, Italy
- Diabetology Unit, Central Tuscany Local Health Unit, Florence, Italy
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Tong J, Li X, Liu T, Liu M. Metformin exposure and the incidence of lactic acidosis in critically ill patients with T2DM: A retrospective cohort study. Sci Prog 2024; 107:368504241262116. [PMID: 39053014 PMCID: PMC11282515 DOI: 10.1177/00368504241262116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
OBJECTIVE The objective of this study was to investigate the correlation between metformin exposure and the incidence of lactic acidosis in critically ill patients. METHODS The patients with type 2 diabetes mellitus (T2DM) were included from Medical Information Mart for Intensive Care IV database (MIMIC-IV). The primary outcome was the incidence of lactic acidosis. The secondary outcomes were lactate level and in-hospital mortality. Propensity score matching (PSM) method was adopted to reduce bias of the confounders. The multivariate logistic regression was used to explore the correlation between metformin exposure and the incidence of lactic acidosis. Subgroup analysis and sensitivity analysis were used to test the stability of the conclusion. RESULTS We included 4939 patients. There were 2070 patients in the metformin group, and 2869 patients in the nonmetformin group. The frequency of lactic acidosis was 5.7% (118/2070) in the metformin group and it was 4.3% (122/2869) in the nonmetformin group. There was a statistically significant difference between the two groups (P < 0.05). The lactate level in the metformin group was higher than in the nonmetformin group (2.78 ± 2.23 vs. 2.45 ± 2.24, P < 0.001). After PSM, the frequency of lactic acidosis (6.3% vs. 3.7%, P < 0.001) and lactate level (2.85 ± 2.38 vs. 2.40 ± 2.14, P < 0.001) were significantly higher in the metformin group compared with the nonmetformin group. In multivariate logistic models, the frequency of lactic acidosis was obviously increased in metformin group, and the adjusted odds ratio (OR) of metformin exposure was 1.852 (95% confidence interval (CI) = 1.298-2.643, P < 0.001). The results were consistent with subgroup analysis except for respiratory failure subgroup. Metformin exposure increased lactate level but did not affect the frequency of lactic acidosis in patients of respiratory failure with hypercapnia. However, the in-hospital mortality between metformin and nonmetformin group had no obvious difference (P = 0.215). In sensitivity analysis, metformin exposure showed similar effect as the original cohort. CONCLUSIONS In critically ill patients with T2DM, metformin exposure elevated the incidence of lactic acidosis except for patients of respiratory failure with hypercapnia, but did not affect the in-hospital mortality.
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Affiliation(s)
- Jingkai Tong
- Tianjin Medical University General Hospital, Tianjin, China
| | - Xin Li
- Tianjin Medical University General Hospital, Tianjin, China
| | - Tong Liu
- Tianjin Medical University General Hospital, Tianjin, China
| | - Ming Liu
- Tianjin Medical University General Hospital, Tianjin, China
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Wagle L, Regmi DR, Regmi R, Poudel S, Pant HN. Metformin Toxicity Leading to Severe Refractory Hyperkalemia and Metabolic Acidosis: A Case Report. Cureus 2024; 16:e63130. [PMID: 39055480 PMCID: PMC11271817 DOI: 10.7759/cureus.63130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Abstract
Metformin is a widely prescribed, oral, anti-diabetic agent for the treatment of type 2 diabetes mellitus (DM2). While generally well-tolerated, metformin can accumulate in patients with acute kidney injury (AKI) or chronic kidney disease (CKD), leading to potentially life-threatening complications such as metformin-associated lactic acidosis (MALA). Severe hyperkalemia is a rare but serious manifestation of metformin toxicity. We report a case of a 74-year-old African American man with DM2, hypertension, and CKD stage 3a, who presented with nausea, vomiting, lethargy, and diarrhea. Laboratory findings revealed severe AKI with a creatinine level of 8 mg/dL (baseline 1.7 mg/dL) and a potassium level of 7.8 mEq/L. The patient developed refractory hyperkalemia requiring multiple interventions and eventually continuous renal replacement therapy. Further evaluation revealed metformin-induced severe lactic acidosis with a metformin level of 21 mcg/mL (therapeutic range <5 mcg/mL). This case highlights the importance of recognizing metformin toxicity as a potential cause of severe, refractory hyperkalemia and metabolic acidosis in patients with AKI or CKD. Early recognition and prompt discontinuation of metformin, along with appropriate management of electrolyte disturbances and metabolic derangements, are crucial in preventing life-threatening complications.
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Affiliation(s)
- Laxman Wagle
- Internal Medicine, Ascension Saint Agnes Hospital, Baltimore, USA
| | - Dhiraj R Regmi
- Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, NPL
| | | | - Sishir Poudel
- Internal Medicine, BP Koirala Institute of Health Sciences, Dharan, NPL
| | - Hom Nath Pant
- Internal Medicine, Ascension Saint Agnes Hospital, Baltimore, USA
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Al-Bari MAA, Peake N, Eid N. Tuberculosis-diabetes comorbidities: Mechanistic insights for clinical considerations and treatment challenges. World J Diabetes 2024; 15:853-866. [PMID: 38766427 PMCID: PMC11099355 DOI: 10.4239/wjd.v15.i5.853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/08/2024] [Accepted: 03/21/2024] [Indexed: 05/10/2024] Open
Abstract
Tuberculosis (TB) remains a leading cause of death among infectious diseases, particularly in poor countries. Viral infections, multidrug-resistant and ex-tensively drug-resistant TB strains, as well as the coexistence of chronic illnesses such as diabetes mellitus (DM) greatly aggravate TB morbidity and mortality. DM [particularly type 2 DM (T2DM)] and TB have converged making their control even more challenging. Two contemporary global epidemics, TB-DM behaves like a syndemic, a synergistic confluence of two highly prevalent diseases. T2DM is a risk factor for developing more severe forms of multi-drug resistant-TB and TB recurrence after preventive treatment. Since a bidirectional relationship exists between TB and DM, it is necessary to concurrently treat both, and promote recommendations for the joint management of both diseases. There are also some drug-drug interactions resulting in adverse treatment outcomes in TB-DM patients including treatment failure, and reinfection. In addition, autophagy may play a role in these comorbidities. Therefore, the TB-DM comorbidities present several health challenges, requiring a focus on multidisciplinary collaboration and integrated strategies, to effectively deal with this double burden. To effectively manage the comorbidity, further screening in affected countries, more suitable drugs, and better treatment strategies are required.
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Affiliation(s)
| | - Nicholas Peake
- Biosciences and Chemistry and Biomolecular Research Centre, Sheffield Hallam University, Sheffield S1 1WB, United Kingdom
| | - Nabil Eid
- Department of Anatomy, Division of Human Biology, School of Medicine, International Medical University, Kuala Lumpur 57000, Malaysia
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Shen LL, Keenan JD, Chahal N, Taha AT, Saroya J, Ma CJ, Sun M, Yang D, Psaras C, Callander J, Flaxel C, Fawzi AA, Schlesinger TK, Wong RW, Bryan Leung LS, Eaton AM, Steinle NC, Telander DG, Afshar AR, Neuwelt MD, Lim JI, Yiu GC, Stewart JM. METformin for the MINimization of Geographic Atrophy Progression (METforMIN): A Randomized Trial. OPHTHALMOLOGY SCIENCE 2024; 4:100440. [PMID: 38284098 PMCID: PMC10810745 DOI: 10.1016/j.xops.2023.100440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/18/2023] [Accepted: 11/27/2023] [Indexed: 01/30/2024]
Abstract
Purpose Metformin use has been associated with a decreased risk of age-related macular degeneration (AMD) progression in observational studies. We aimed to evaluate the efficacy of oral metformin for slowing geographic atrophy (GA) progression. Design Parallel-group, multicenter, randomized phase II clinical trial. Participants Participants aged ≥ 55 years without diabetes who had GA from atrophic AMD in ≥ 1 eye. Methods We enrolled participants across 12 clinical centers and randomized participants in a 1:1 ratio to receive oral metformin (2000 mg daily) or observation for 18 months. Fundus autofluorescence imaging was obtained at baseline and every 6 months. Main Outcome Measures The primary efficacy endpoint was the annualized enlargement rate of the square root-transformed GA area. Secondary endpoints included best-corrected visual acuity (BCVA) and low luminance visual acuity (LLVA) at each visit. Results Of 66 enrolled participants, 34 (57 eyes) were randomized to the observation group and 32 (53 eyes) were randomized to the treatment group. The median follow-up duration was 13.9 and 12.6 months in the observation and metformin groups, respectively. The mean ± standard error annualized enlargement rate of square root transformed GA area was 0.35 ± 0.04 mm/year in the observation group and 0.42 ± 0.04 mm/year in the treatment group (risk difference = 0.07 mm/year, 95% confidence interval = -0.05 to 0.18 mm/year; P = 0.26). The mean ± standard error decline in BCVA was 4.8 ± 1.7 letters/year in the observation group and 3.4 ± 1.1 letters/year in the treatment group (P = 0.56). The mean ± standard error decline in LLVA was 7.3 ± 2.5 letters/year in the observation group and 0.8 ± 2.2 letters/year in the treatment group (P = 0.06). Fourteen participants in the metformin group experienced nonserious adverse events related to metformin, with gastrointestinal side effects as the most common. No serious adverse events were attributed to metformin. Conclusions The results of this trial as conducted do not support oral metformin having effects on reducing the progression of GA. Additional placebo-controlled trials are needed to explore the role of metformin for AMD, especially for earlier stages of the disease. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Liangbo Linus Shen
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Jeremy D Keenan
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Noor Chahal
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Abu Tahir Taha
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Jasmeet Saroya
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Chu Jian Ma
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Mengyuan Sun
- Institute of Cardiovascular Diseases, Gladstone Institute, San Francisco, California
| | - Daphne Yang
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Catherine Psaras
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Jacquelyn Callander
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Christina Flaxel
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Amani A Fawzi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Loh-Shan Bryan Leung
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California
| | | | | | | | - Armin R Afshar
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Melissa D Neuwelt
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Jennifer I Lim
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Glenn C Yiu
- Department of Ophthalmology & Visual Sciences, UC Davis Medical Center, Sacramento, California
| | - Jay M Stewart
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California
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Gulanski BI, Goulet JL, Radhakrishnan K, Ko J, Li Y, Rajeevan N, Lee KM, Heberer K, Lynch JA, Streja E, Mutalik P, Cheung KH, Concato J, Shih MC, Lee JS, Aslan M. Metformin prescription for U.S. veterans with prediabetes, 2010-2019. J Investig Med 2024; 72:139-150. [PMID: 37668313 DOI: 10.1177/10815589231201141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
Affecting an estimated 88 million Americans, prediabetes increases the risk for developing type 2 diabetes mellitus (T2DM), and independently, cardiovascular disease, retinopathy, nephropathy, and neuropathy. Nevertheless, little is known about the use of metformin for diabetes prevention among patients in the Veterans Health Administration, the largest integrated healthcare system in the U.S. This is a retrospective observational cohort study of the proportion of Veterans with incident prediabetes who were prescribed metformin at the Veterans Health Administration from October 2010 to September 2019. Among 1,059,605 Veterans with incident prediabetes, 12,009 (1.1%) were prescribed metformin during an average 3.4 years of observation after diagnosis. Metformin prescribing was marginally higher (1.6%) among those with body mass index (BMI) ≥35 kg/m2, age <60 years, HbA1c≥6.0%, or those with a history of gestational diabetes, all subgroups at a higher risk for progression to T2DM. In a multivariable model, metformin was more likely to be prescribed for those with BMI ≥35 kg/m2 incidence rate ratio [IRR] 2.6 [95% confidence intervals (CI): 2.1-3.3], female sex IRR, 2.4 [95% CI: 1.8-3.3], HbA1c≥6% IRR, 1.93 [95% CI: 1.5-2.4], age <60 years IRR, 1.7 [95% CI: 1.3-2.3], hypertriglyceridemia IRR, 1.5 [95% CI: 1.2-1.9], hypertension IRR, 1.5 [95% CI: 1.1-2.1], Major Depressive Disorder IRR, 1.5 [95% CI: 1.1-2.0], or schizophrenia IRR, 2.1 [95% CI: 1.2-3.8]. Over 20% of Veterans with prediabetes attended a comprehensive structured lifestyle modification clinic or program. Among Veterans with prediabetes, metformin was prescribed to 1.1% overall, a proportion that marginally increased to 1.6% in the subset of individuals at highest risk for progression to T2DM.
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Affiliation(s)
- Barbara I Gulanski
- Department of Medicine, Endocrinology, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph L Goulet
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- Pain, Research, Informatics, Multi-morbidities and Education Center (PRIME), West Haven, CT, USA
| | - Krishnan Radhakrishnan
- National Mental Health and Substance Use Policy Laboratory, Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
| | - John Ko
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Yuli Li
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Nallakkandi Rajeevan
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Kyung Min Lee
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Kent Heberer
- VA Palo Alto Cooperative Studies Program Coordinating Center, VA Palo Alto Heath Care System, CA, USA
- Division of Endocrinology, Gerontology, and Metabolism, Department of Medicine, Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Julie A Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elani Streja
- Department of Medicine, Nephrology, Hypertension and Transplant, University of California-Irvine School of Medicine, Long Beach, CA, USA
| | - Pradeep Mutalik
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
| | - Kei-Hoi Cheung
- Section of Biomedical Informatics and Data Science, Yale University School of Medicine, New Haven, CT, USA
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - John Concato
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Mei-Chiung Shih
- VA Palo Alto Cooperative Studies Program Coordinating Center, VA Palo Alto Heath Care System, CA, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer S Lee
- VA Palo Alto Cooperative Studies Program Coordinating Center, VA Palo Alto Heath Care System, CA, USA
- Division of Endocrinology, Gerontology, and Metabolism, Department of Medicine, Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mihaela Aslan
- VA Cooperative Studies Program Clinical Epidemiology Research Center (CSP-CERC), VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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Ritsinger V, Hagström E, Hambraeus K, James S, Jernberg T, Lagerqvist B, Leosdottir M, Lundman P, Pernow J, Östlund O, Norhammar A. Design and rationale of the myocardial infarction and new treatment with metformin study (MIMET) - Study protocol for a registry-based randomised clinical trial. J Diabetes Complications 2023; 37:108599. [PMID: 37683518 DOI: 10.1016/j.jdiacomp.2023.108599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023]
Abstract
AIMS To investigate if addition of metformin to standard care (life-style advice) reduces the occurrence of cardiovascular events and death after myocardial infarction (MI) in patients with newly detected prediabetes. METHODS The Myocardial Infarction and new treatment with Metformin study (MIMET) is a large multicentre registry-based randomised clinical trial (R-RCT) within the SWEDEHEART registry platform expected to include 5160 patients with MI and newly detected prediabetes (identified with fasting blood glucose, HbA1c or 2-h glucose on oral glucose tolerance test) at ∼20 study sites in Sweden. Patients 18-80 years, without known diabetes and naïve to glucose lowering therapy, will be randomised 1:1 to open-label metformin therapy plus standard care or standard care alone. OUTCOMES Patients will be followed for 2 years for the primary outcome new cardiovascular event (first of death, non-fatal MI, hospitalisation for heart failure or non-fatal stroke). Secondary endpoints include individual components of the primary endpoint, diabetes diagnosis, initiation of any glucose lowering therapy, cancer, and treatment safety. Events will be collected from national healthcare registries. CONCLUSIONS The MIMET study will investigate if metformin is superior to standard care after myocardial infarction in preventing cardiovascular events in patients with prediabetes (Clinicaltrials.gov identifier: NCT05182970; EudraCT No: 2019-001487-30).
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Affiliation(s)
- Viveca Ritsinger
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Research and Development, Region Kronoberg, Växjö, Sweden.
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Margrét Leosdottir
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Pia Lundman
- Department of Clinical Sciences, Cardiology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - John Pernow
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ollie Östlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Anna Norhammar
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Capio S:t Görans Hospital, Stockholm, Sweden
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Nakamura K, Abe N, Horita T. Thiamine Deficiency Manifesting Acute Right Hypochondrial Pain with Lactic Acidosis. Am J Med 2023; 136:e202-e203. [PMID: 37369270 DOI: 10.1016/j.amjmed.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Koki Nakamura
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
| | - Nobuya Abe
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan.
| | - Tetsuya Horita
- Department of Internal Medicine, Tomakomai City Hospital, Tomakomai, Japan
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Bramante CT, Buse JB, Liebovitz DM, Nicklas JM, Puskarich MA, Cohen K, Belani HK, Anderson BJ, Huling JD, Tignanelli CJ, Thompson JL, Pullen M, Wirtz EL, Siegel LK, Proper JL, Odde DJ, Klatt NR, Sherwood NE, Lindberg SM, Karger AB, Beckman KB, Erickson SM, Fenno SL, Hartman KM, Rose MR, Mehta T, Patel B, Griffiths G, Bhat NS, Murray TA, Boulware DR. Outpatient treatment of COVID-19 and incidence of post-COVID-19 condition over 10 months (COVID-OUT): a multicentre, randomised, quadruple-blind, parallel-group, phase 3 trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:1119-1129. [PMID: 37302406 PMCID: PMC11259948 DOI: 10.1016/s1473-3099(23)00299-2] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/30/2023] [Accepted: 05/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Post-COVID-19 condition (also known as long COVID) is an emerging chronic illness potentially affecting millions of people. We aimed to evaluate whether outpatient COVID-19 treatment with metformin, ivermectin, or fluvoxamine soon after SARS-CoV-2 infection could reduce the risk of long COVID. METHODS We conducted a decentralised, randomised, quadruple-blind, parallel-group, phase 3 trial (COVID-OUT) at six sites in the USA. We included adults aged 30-85 years with overweight or obesity who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days before enrolment. Participants were randomly assigned via 2 × 3 parallel factorial randomisation (1:1:1:1:1:1) to receive metformin plus ivermectin, metformin plus fluvoxamine, metformin plus placebo, ivermectin plus placebo, fluvoxamine plus placebo, or placebo plus placebo. Participants, investigators, care providers, and outcomes assessors were masked to study group assignment. The primary outcome was severe COVID-19 by day 14, and those data have been published previously. Because the trial was delivered remotely nationwide, the a priori primary sample was a modified intention-to-treat sample, meaning that participants who did not receive any dose of study treatment were excluded. Long COVID diagnosis by a medical provider was a prespecified, long-term secondary outcome. This trial is complete and is registered with ClinicalTrials.gov, NCT04510194. FINDINGS Between Dec 30, 2020, and Jan 28, 2022, 6602 people were assessed for eligibility and 1431 were enrolled and randomly assigned. Of 1323 participants who received a dose of study treatment and were included in the modified intention-to-treat population, 1126 consented for long-term follow-up and completed at least one survey after the assessment for long COVID at day 180 (564 received metformin and 562 received matched placebo; a subset of participants in the metformin vs placebo trial were also randomly assigned to receive ivermectin or fluvoxamine). 1074 (95%) of 1126 participants completed at least 9 months of follow-up. 632 (56·1%) of 1126 participants were female and 494 (43·9%) were male; 44 (7·0%) of 632 women were pregnant. The median age was 45 years (IQR 37-54) and median BMI was 29·8 kg/m2 (IQR 27·0-34·2). Overall, 93 (8·3%) of 1126 participants reported receipt of a long COVID diagnosis by day 300. The cumulative incidence of long COVID by day 300 was 6·3% (95% CI 4·2-8·2) in participants who received metformin and 10·4% (7·8-12·9) in those who received identical metformin placebo (hazard ratio [HR] 0·59, 95% CI 0·39-0·89; p=0·012). The metformin beneficial effect was consistent across prespecified subgroups. When metformin was started within 3 days of symptom onset, the HR was 0·37 (95% CI 0·15-0·95). There was no effect on cumulative incidence of long COVID with ivermectin (HR 0·99, 95% CI 0·59-1·64) or fluvoxamine (1·36, 0·78-2·34) compared with placebo. INTERPRETATION Outpatient treatment with metformin reduced long COVID incidence by about 41%, with an absolute reduction of 4·1%, compared with placebo. Metformin has clinical benefits when used as outpatient treatment for COVID-19 and is globally available, low-cost, and safe. FUNDING Parsemus Foundation; Rainwater Charitable Foundation; Fast Grants; UnitedHealth Group Foundation; National Institute of Diabetes, Digestive and Kidney Diseases; National Institutes of Health; and National Center for Advancing Translational Sciences.
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Affiliation(s)
- Carolyn T Bramante
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC, USA
| | - David M Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View, University of California, Los Angeles, CA, USA
| | - Blake J Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA; Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Pullen
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer L Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David J Odde
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sarah M Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | | | - Spencer M Erickson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L Fenno
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M Hartman
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Rose
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Gwendolyn Griffiths
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Neeta S Bhat
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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10
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Gracia-Ramos AE, Carretero-Gómez J, Mendez CE, Carrasco-Sánchez FJ. Evidence-based therapeutics for hyperglycemia in hospitalized noncritically ill patients. Curr Med Res Opin 2022; 38:43-53. [PMID: 34694181 DOI: 10.1080/03007995.2021.1997288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hyperglycemia in hospitalized patients, either with or without diabetes, is a common, serious, and costly healthcare problem. Evidence accumulated over 20 years has associated hyperglycemia with a significant increase in morbidity and mortality, both in surgical and medical patients. Based on this documented link between hyperglycemia and poor outcomes, clinical guidelines from professional organizations recommend the treatment of hospital hyperglycemia with a therapeutic goal of maintaining blood glucose (BG) levels less than 180 mg/dL. Insulin therapy remains a mainstay of glycemic management in the inpatient setting. The use of non-insulin antidiabetic drugs in the hospital setting is limited because little data are available regarding their safety and efficacy. However, information about the use of incretin-based therapy in inpatients has increased in the past 15 years. This review aims to summarize the different treatment strategies for hyperglycemia in hospitalized noncritical patients that are supported by observational studies or clinical trials with insulin and non-insulin drugs. In addition, we propose a protocol to help with the management of this important clinical problem.
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Affiliation(s)
- Abraham Edgar Gracia-Ramos
- Department of Internal Medicine, General Hospital, National Medicinal Center "La Raza," Instituto Mexicano del Seguro Social, Mexico City, Mexico
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
| | | | - Carlos E Mendez
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Diabetes and Endocrinology, Milwaukee VA Medical Center, Milwaukee, WI, USA
| | - Francisco Javier Carrasco-Sánchez
- Department of Internal Medicine, Diabetes and Cardiovascular Risk Factor Unit, University Hospital Juan Ramón Jimenez, Huelva, Spain
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11
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Kim MH, Oh HJ, Kwon SH, Jeon JS, Noh H, Han DC, Kim H, Ryu DR. Metformin use and cardiovascular outcomes in patients with diabetes and chronic kidney disease: a nationwide cohort study. Kidney Res Clin Pract 2021; 40:660-672. [PMID: 34922433 PMCID: PMC8685353 DOI: 10.23876/j.krcp.20.222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Metformin has recently been shown not to increase the risk of lactic acidosis in patients with chronic kidney disease (CKD). Thus, the criteria for metformin use in this population has expanded. However, the relationship between metformin use and clinical outcomes in CKD remains controversial. METHODS This study considered data from 97,713 diabetes patients with an estimated glomerular filtration rate of <60 mL/min/1.73 m2. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), and the secondary outcomes were all-cause mortality and incident end-stage renal disease (ESRD). RESULTS Metformin users had a significantly higher risk of MACCE than non-users (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.14-1.26; p < 0.001). However, metformin users had a lower risk of all-cause mortality (HR, 0.78; 95% CI, 0.74-0.81; p < 0.001) and ESRD (HR, 0.44; 95% CI, 0.42-0.47; p < 0.001) during follow-up than non-users did. The relationships between metformin use and clinical outcomes remained consistent in propensity score matching analyses and subgroup analyses of patients with adequate adherence to anti-diabetes medication. CONCLUSION Treatment with metformin was associated with an increased risk of MACCE in patients with diabetes and CKD. However, metformin users had a lower risk of all-cause mortality and ESRD during follow-up than non-users did. Therefore, metformin needs to be carefully used in patients with CKD.
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Affiliation(s)
- Min-Ho Kim
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Hyung Jung Oh
- Department of Nephrology, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, UAE
| | - Soon Hyo Kwon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jin Seok Jeon
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyunjin Noh
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Dong Cheol Han
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyoungnae Kim
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Hyonam Kidney Laboratory, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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12
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Abstract
Medications used to treat diabetes mellitus are heterogeneous, with widely differing safety profiles in therapeutic use and in overdose. Insulin overdose may produce severe and prolonged hypoglycemia. Sulfonylurea poisoning should be treated with octreotide, sparing intravenous dextrose where possible. Acute metformin overdose may lead to life-threatening acidosis with elevated lactate concentrations, which may require hemodialysis. Glucagon-like peptide 1 agonists and dipeptidyl peptidase 4 inhibitors are benign in overdose in diabetic patients but may produce profound hypoglycemia in nondiabetic patients. Euglycemic diabetic ketoacidosis may develop in critically ill patients taking sodium-glucose co-transporter 2 inhibitors.
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Affiliation(s)
- Kevin Baumgartner
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8072, St Louis, MO 63110, USA.
| | - Jason Devgun
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8072, St Louis, MO 63110, USA
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13
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Fadden EJ, Longley C, Mahambrey T. Metformin-associated lactic acidosis. BMJ Case Rep 2021; 14:14/7/e239154. [PMID: 34244196 DOI: 10.1136/bcr-2020-239154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 58-year-old female with known type 2 diabetes mellitus continued to take her usual medications, including metformin, an ACE inhibitor and a non-steroidal anti-inflammatory drug, while suffering from diarrhoea and vomiting. On presentation to the emergency department, she was found to have a profound lactic acidosis, cardiovascular instability and acute kidney injury. Despite a pH of 6.6, lactate of 14 mmol/L and a brief asystolic cardiac arrest, supportive treatment and the use of renal replacement therapy resulted in rapid improvement in her acid-base abnormalities and haemodynamic parameters. Metformin-associated lactic acidosis is a rare but life-threatening complication of diabetes management. Patient education and awareness amongst clinicians are paramount in the prevention and treatment of this condition.
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Affiliation(s)
- Emma Jane Fadden
- Critical Care, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Christian Longley
- Critical Care, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Tushar Mahambrey
- Critical Care, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
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14
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Goonoo MS, Morris R, Raithatha A, Creagh F. Republished: Metformin-associated lactic acidosis: reinforcing learning points. Drug Ther Bull 2021; 59:124-127. [PMID: 34031180 DOI: 10.1136/dtb.2021.235608rep] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Mohummad Shaan Goonoo
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Morris
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ajay Raithatha
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fionuala Creagh
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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15
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Bjällmark A, Bazzi M, Karlsson M, Krakys E, Kihlberg J. Radiology departmental policy compliance with Swedish guidelines regarding post-contrast acute kidney injury for examinations with iodinated contrast media. Radiography (Lond) 2021; 27:1058-1063. [PMID: 34023227 DOI: 10.1016/j.radi.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Guidelines concerning intravenous iodinated contrast media (CM) during computed tomography (CT) examinations are important to follow to minimize the risk for post-contrast acute kidney injury (PC-AKI). The purpose of this study was to investigate the radiology departmental policy compliance with Swedish guidelines concerning PC-AKI. METHODS In February 2020, an electronic survey was distributed to the responsible radiographer at 41 radiology departments in all university hospitals and medium-sized hospitals in Sweden. The questions focused on routines around renal functional tests, individualized contrast administration and handling of patients with diabetes mellitus taking metformin. RESULTS The response rate was 83%. Seventy-six percent (n = 26) of radiology departments calculated estimated glomerular filtration rate (eGFR) from serum creatinine prior to CM administration, but only 24% (n = 8) followed the recommendation to calculate eGFR from both serum creatinine and cystatin C. For acute/inpatients, 55% (n = 18) followed the recommendation that renal functional tests should be performed within 12 h before CM administration. For elective patients, 97% (n = 33) followed the recommendation to have eGFR newer than three months which is acceptable for patients with no history of disease that may have affected renal function. Approximately 80% of the radiology departments followed the recommendation that CM dose always should be individually adjusted to patient eGFR. Seventy-six percent (n = 26) followed the recommendation to continue with metformin at eGFR ≥ 45 ml/min. CONCLUSION Compliance with the national guidelines was high regarding routines around renal functional tests, dose adjustment of CM and metformin discontinuation. Improvements can be made in using both cystatin C and serum creatinine for eGFR calculations as well as ensuring renal function tests within 12 h for acute/inpatients with acute disease that may affect renal function. IMPLICATIONS FOR PRACTICE This study raises awareness of the importance of adhering to guidelines in healthcare. To have knowledge about the current level of compliance regarding PCI-AKI is important to maintain and develop effective clinical implementation of guidelines. The variation in practice seen in this study emphasizes the need of more effective implementation strategies to ensure adherence with best practice.
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Affiliation(s)
- A Bjällmark
- Department of Natural Science and Biomedicine, School of Health and Welfare, Jönköping University, Jönköping, Sweden.
| | - M Bazzi
- Department of Natural Science and Biomedicine, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - M Karlsson
- Department of Radiology, Höglandssjukhuset, Eksjö, Sweden
| | - E Krakys
- Department of Radiology, Motala Hospital, Motala, Sweden
| | - J Kihlberg
- Department of Radiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
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16
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Kuan IHS, Wilson LC, Leishman JC, Cosgrove S, Walker RJ, Putt TL, Schollum JBW, Wright DFB. Metformin doses to ensure efficacy and safety in patients with reduced kidney function. PLoS One 2021; 16:e0246247. [PMID: 33600406 PMCID: PMC7891741 DOI: 10.1371/journal.pone.0246247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/18/2021] [Indexed: 01/31/2023] Open
Abstract
We aimed to develop a metformin dosing strategy to optimise efficacy and safety in patients with reduced kidney function. Metformin data from two studies stratified by kidney function were analysed. The relationship between metformin clearance and kidney function estimates was explored using a regression analysis. The maintenance dose range was predicted at different bands of kidney function to achieve an efficacy target of 1 mg/L for steady-state plasma concentrations. The dosing strategy was evaluated using simulations from a published metformin pharmacokinetic model to determine the probability of concentrations exceeding those associated with lactic acidosis risk, i.e. a steady-state average concentration of 3 mg/L and a maximum (peak) concentration of 5 mg/L. A strong relationship between metformin clearance and estimated kidney function using the Cockcroft and Gault (r2 = 0.699), MDRD (r2 = 0.717) and CKD-Epi (r2 = 0.735) equations was found. The probability of exceeding the safety targets for plasma metformin concentration was <5% for most doses and kidney function levels. The lower dose of 500 mg daily was required to maintain concentrations below the safety limits for patients with an eGFR of 15-29 mL/min. Our analysis suggests that a maximum daily dose of 2250, 1700, 1250, 1000, and 500 in patients with normal kidney function, CKD stage 2, 3a, 3b and 4, respectively, will provide a reasonable probability of achieving efficacy and safety. Our results support the cautious of use metformin at appropriate doses in patients with impaired kidney function.
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Affiliation(s)
| | - Luke C. Wilson
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Jed C. Leishman
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Samuel Cosgrove
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Robert J. Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Tracey L. Putt
- Department of Medicine, University of Otago, Dunedin, New Zealand
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17
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Fubini PE, Suppan L. Prehospital Diagnosis of Shortness of Breath Caused by Profound Metformin-Associated Metabolic Acidosis. Healthcare (Basel) 2021; 9:74. [PMID: 33466796 PMCID: PMC7830625 DOI: 10.3390/healthcare9010074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/17/2022] Open
Abstract
Shortness of breath is a common complaint among patients in emergency medicine. While most common causes are usually promptly identified, less frequent aetiologies might be challenging to diagnose, especially in the pre-hospital setting. We report a case of prehospital dyspnoea initially ascribed to pulmonary oedema which turned out to be the result of profound metformin-associated metabolic acidosis. This diagnosis was already made during the prehospital phase by virtue of arterial blood gas measurement. Pre-hospital measurement of arterial blood gases is therefore feasible and can improve diagnostic accuracy in the field, thus avoiding unnecessary delay and potential harm to the patient before initiating the appropriate therapeutic actions.
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Affiliation(s)
- Pietro Elias Fubini
- Division of Intensive Care Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine University of Geneva, CH-1211 Geneva, Switzerland
| | - Laurent Suppan
- Division of Emergency Medicine, Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine University of Geneva, CH-1211 Geneva, Switzerland;
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18
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Bhat JA, Masoodi SR, Bhat MH, Bhat H, Ahmad PO, Sood M. Lactic Acidosis in Diabetic Ketoacidosis: A Marker of Severity or Alternate Substrate for Metabolism. Indian J Endocrinol Metab 2021; 25:59-66. [PMID: 34386396 PMCID: PMC8323635 DOI: 10.4103/ijem.ijem_753_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/12/2020] [Accepted: 03/07/2021] [Indexed: 11/04/2022] Open
Abstract
PURPOSE The lactate level is being increasingly used as a marker of severity of illness and prognosis in multitude of critical conditions. However, its role in diabetic ketoacidosis (DKA) is not well defined. AIM To determine the prevalence and clinical importance along with the underlying role of metformin in lactic acidosis (LA) in patients admitted with DKA. METHODS A 2-year prospective and observational study involving 62 consenting in hospital DKA patients. Plasma lactate level on arrival, its clinical significance and relationship with morbidity and mortality in patients with DKA was evaluated. RESULTS The prevalence of LA (lactate ≥2.5 mmol/l) among the study cohort was found to be 55% with significant LA (≥5 mmol/l) documented in 16%. The median lactate level was 2.55 mmol/l (interquartile range, 1.70-3.20). No significant difference in the severity of LA was seen with metformin use. Lactate correlated positively with initial plasma glucose (IPG) (P = 0.001) and APACHE-II Score (P = 0.002); correlated negatively with systolic blood pressure (P = 0.003), pH (P = 0.002) and severity of DKA (P = 0.001). After controlling for AKI, APACHE II score and blood pressure, lactate continued to correlate positively with IPG (P = 0.002). No mortality or significant morbidity was documented in the entire cohort. CONCLUSIONS LA has a significant presence in patients with DKA; however, it is not associated with mortality or significant morbidity. Moreover, there was no significant difference in severity of LA with metformin use. Elevated lactate levels may be an adaptation to provide alternate substrate for metabolism in the presence of hypoinsulinemic state. The study results provide rationale for large well-designed studies evaluating in-depth clinical relationship of lactate in DKA.
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Affiliation(s)
- Javaid Ahmad Bhat
- Department of Endocrinology, Superspeciality Hospital, GMC, Srinagar, Kashmir, India
| | - Shariq Rashid Masoodi
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Moomin Hussain Bhat
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Hilal Bhat
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Peerzada Ovais Ahmad
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Mona Sood
- Department of Endocrinology, SheriKashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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19
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Wiggers H, Køber L, Gislason G, Schou M, Poulsen MK, Vraa S, Nielsen OW, Bruun NE, Nørrelund H, Hollingdal M, Barasa A, Bøttcher M, Dodt K, Hansen VB, Nielsen G, Knudsen AS, Lomholdt J, Mikkelsen KV, Jonczy B, Brønnum-Schou J, Poenaru MP, Abdulla J, Raymond I, Mahboubi K, Sillesen K, Serup-Hansen K, Madsen JS, Kristensen SL, Larsen AH, Bøtker HE, Torp-Petersen C, Eiskjær H, Møller J, Hassager C, Steffensen FH, Bibby BM, Refsgaard J, Høfsten DE, Mellemkjær S, Gustafsson F. The DANish randomized, double-blind, placebo controlled trial in patients with chronic HEART failure (DANHEART): A 2 × 2 factorial trial of hydralazine-isosorbide dinitrate in patients with chronic heart failure (H-HeFT) and metformin in patients with chronic heart failure and diabetes or prediabetes (Met-HeFT). Am Heart J 2021; 231:137-146. [PMID: 33039340 PMCID: PMC7544566 DOI: 10.1016/j.ahj.2020.09.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/24/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The DANHEART trial is a multicenter, randomized (1:1), parallel-group, double-blind, placebo-controlled study in chronic heart failure patients with reduced ejection fraction (HFrEF). This investigator driven study will include 1500 HFrEF patients and test in a 2 × 2 factorial design: 1) if hydralazine-isosorbide dinitrate reduces the incidence of death and hospitalization with worsening heart failure vs. placebo (H-HeFT) and 2) if metformin reduces the incidence of death, worsening heart failure, acute myocardial infarction, and stroke vs. placebo in patients with diabetes or prediabetes (Met-HeFT). METHODS Symptomatic, optimally treated HFrEF patients with LVEF ≤40% are randomized to active vs. placebo treatment. Patients can be randomized in either both H-HeFT and Met-HeFT or to only one of these study arms. In this event-driven study, it is anticipated that 1300 patients should be included in H-HeFT and 1100 in Met-HeFT and followed for an average of 4 years. RESULTS As of May 2020, 296 patients have been randomized at 20 centers in Denmark. CONCLUSION The H-HeFT and Met-HeFT studies will yield new knowledge about the potential benefit and safety of 2 commonly prescribed drugs with limited randomized data in patients with HFrEF.
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Affiliation(s)
- Henrik Wiggers
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Morten Schou
- Department of Cardiology, Herlev Hospital, Denmark
| | | | - Søren Vraa
- Department of Cardiology, Aalborg University Hospital, Denmark
| | | | | | | | | | - Anders Barasa
- Department of Cardiology, Hvidovre Hospital, Denmark
| | | | - Karen Dodt
- Department of Cardiology, Horsens Hospital, Denmark
| | | | - Gitte Nielsen
- Department of Cardiology, Hjørring Hospital, Denmark
| | | | - Jens Lomholdt
- Department of Cardiology, Slagelse Hospital, Denmark
| | | | | | | | | | - Jawdat Abdulla
- Department of Medicine, Cardiology Section, Glostrup Hospital, Denmark
| | - Ilan Raymond
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | | | | | | | | | | | | | | | | | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Denmark
| | - Jacob Møller
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Bo Martin Bibby
- Department of Biostatistics, Aarhus University, Aarhus, Denmark
| | | | - Dan Eik Høfsten
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
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20
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Papadakis G, Kandaraki EA, Garidou A, Koutsaki M, Papalou O, Diamanti-Kandarakis E, Peppa M. Tailoring treatment for PCOS phenotypes. Expert Rev Endocrinol Metab 2021; 16:9-18. [PMID: 33382003 DOI: 10.1080/17446651.2021.1865152] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/14/2020] [Indexed: 12/17/2022]
Abstract
Introduction: Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in reproductive-aged women. Hyperandrogenism, polycystic ovaries, chronic anovulation, and metabolic aberrations are its common features. The treatment approach focuses on the main aberrations, which characterize the different phenotypes. Areas covered: Management strategies targeting the metabolic phenotype include lifestyle modifications for weight loss and improvement of dietary habits, as well as medication, such as insulin-sensitizers. The treatment of hyperandrogenic phenotype includes cosmetic procedures and the combined oral contraceptives with or without antiandrogens. The therapeutic approach to reproductive phenotype includes diet and lifestyle modifications, clomiphene citrate, and aromatase inhibitors. Alternative treatments include dietary supplements, herbs, resveratrol, myo-inositol, and acupuncture. Expert opinion: New studies have shown that higher anti-Müllerian hormone levels, gut microbiome composition, and plasma metabolomics are new parameters that are related to the most severe phenotypes. The clinical phenotypes can change over the lifespan with weight gain and can coexist in the same individual. Individualized treatment remains the main approach but grouping the phenotypes and following therapeutic recommendations may prove to be also clinically appropriate.
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Affiliation(s)
- Georgios Papadakis
- Endocrinology and Diabetes, STEPS Stoffwechselzentrum , Biel/Bienne, Switzerland
| | - Eleni A Kandaraki
- Endocrinology &Diabetes, European University Cyprus (EUC) , Nicosia, Cyprus
- Department of Endocrinology and Diabetes, HYGEIA Hospital Athens , Greece
| | - Anna Garidou
- Private Practice, Endocrinologist and Diabetologist , Chalandri, Athens, Greece
| | - Maria Koutsaki
- Private Practice, Endocrinologist and Diabetologist , Kesariani, Athens, Greece
| | - Olga Papalou
- Department of Endocrinology and Diabetes, HYGEIA Hospital Athens , Greece
| | | | - Melpomeni Peppa
- Endocrine Unit, 2nd Department of Internal Medicine Propaedeutic, Research Institute and Diabetes Center, National and Kapodistrian University of Athens, Attikon University Hospital , Greece
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Alvarez CA, Halm EA, Pugh MJV, McGuire DK, Hennessy S, Miller RT, Lingvay I, Vouri SM, Zullo AR, Yang H, Chansard M, Mortensen EM. Lactic acidosis incidence with metformin in patients with type 2 diabetes and chronic kidney disease: A retrospective nested case-control study. Endocrinol Diabetes Metab 2021; 4:e00170. [PMID: 33532612 PMCID: PMC7831229 DOI: 10.1002/edm2.170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 05/28/2020] [Accepted: 06/27/2020] [Indexed: 12/12/2022] Open
Abstract
Objective Compare rates of lactic acidosis (LA) among metformin-exposed and unexposed patients with type 2 diabetes mellitus and varying degrees of chronic kidney disease (CKD). Research Design and Methods Retrospective, nested case-control study using data from national VA Corporate Data Warehouse. All adult patients with type 2 diabetes and CKD newly dispensed any antihyperglycaemic medication during FY 2003-13 were included. The outcome was LA hospitalization or serum lactate >5 mEq/L. Exposure to metformin was evaluated in the three months prior to event. Estimates were adjusted for 31 covariates, including demographics, comorbidities and medications. Results Overall, 320 882 patients were included, contributing a total of 1 331 784 person-years of follow-up. LA occurred in 2 665 patients, generating an overall incidence rate of 2.00 (95% CI 1.93-2.08) per 1000 person-years. Metformin exposure in the prior 3 months was associated with an elevated adjusted hazard of LA (HR 1.97, 95% CI 1.69-2.29). No association was evident in patients with CKD stage 1 or 2 (HR 1.05, 95% CI 0.71-1.57), but associations were present and progressively greater in patients with CKD stage 3a through 5: HR 3.09, 95% CI 2.19-4.35 in CKD 3a, HR 3.34, 95% CI 1.95-5.72 in CKD 3b, HR 7.87, 95% CI 3.51-17.61 in CKD stage 4&5. Conclusion Metformin was not associated with an elevated risk of LA in persons with stage 1-2 CKD, but was associated with a progressively higher risk at more advanced stages of CKD.
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Affiliation(s)
- Carlos A. Alvarez
- Texas Tech University Health Sciences CenterSchool of PharmacyDallasTXUSA
- University of Texas Southwestern Medical CenterDallasTXUSA
- Veterans Affairs North Texas Health Care SystemDallasTXUSA
| | - Ethan A. Halm
- University of Texas Southwestern Medical CenterDallasTXUSA
| | | | | | - Sean Hennessy
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Richard T. Miller
- University of Texas Southwestern Medical CenterDallasTXUSA
- Veterans Affairs North Texas Health Care SystemDallasTXUSA
| | - Ildiko Lingvay
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Scott M. Vouri
- University of Florida College of PharmacyGainesvilleFLUSA
| | - Andrew R. Zullo
- Brown University School of Public Health and Providence Veterans Affairs Medical CenterProvidenceRIUSA
| | - Hui Yang
- Texas Tech University Health Sciences CenterSchool of PharmacyDallasTXUSA
| | - Matt Chansard
- University of Texas Southwestern Medical CenterDallasTXUSA
| | - Eric M. Mortensen
- University of Texas Southwestern Medical CenterDallasTXUSA
- Veterans Affairs North Texas Health Care SystemDallasTXUSA
- University of Connecticut School of MedicineFarmingtonCTUSA
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Ren C, Wang J, Tan Y, Guo M, Guo J, Liu Y, Wu X, Feng Y. Synthesis, Characterization and Biological Evaluation of Magnolol and Honokiol Derivatives with 1,3,5-Triazine of Metformin Cyclization. Molecules 2020; 25:E5779. [PMID: 33302335 PMCID: PMC7762331 DOI: 10.3390/molecules25245779] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 01/17/2023] Open
Abstract
Herein, we sought to evaluate the contribution of the 1,3,5-triazine ring through the metformin cyclization unit to the biological activity of magnolol and honokiol-conjugates. One of the phenolic OH groups of magnolol or honokiol was replaced by a 1,3,5-triazine ring to further explore their synthesis and medicinal versatility. In this study, a robust procedure of three steps was adopted for the synthesis of magnolol and honokiol derivatives by alkylation of potassium carbonate with a 1,3,5-triazine ring. To our knowledge, this is the first report to connect one of the phenolic OH positions of magnolol or honokiol to a 1,3,5-triazine ring cyclized by metformin. The structural characterization of three new compounds was carried out via spectroscopic techniques, i.e., 13C NMR, 1H NMR, and HRMS. Surprisingly, these compounds showed no cytotoxicity against RAW 264.7 macrophages but significantly inhibited the proliferation of MCF-7 (human breast cancer cells), HepG2 (human hepatoma cells), A549 (human lung carcinoma cells), and BxPC-3 (human pancreatic carcinoma cells) tumor cell lines. Furthermore, the compounds also significantly inhibited the release of inflammatory cytokines, including nitric oxide (NO), tumor necrosis factor-α (TNF-α), and interleukin-1β (IL-1β) in the lipopolysaccharide (LPS)-activated mouse cells (RAW 264.7). Among them, compound 2 demonstrated promising broad-spectrum antiproliferative potential with half inhibitory concentration (IC50) values ranging from 5.57 to 8.74 µM and it significantly decreased caspase-3 and Bcl-2 expression in HepG2 cells. These interesting findings show that derivatization of magnolol and honokiol with 1,3,5-triazine affects and modulates their biological properties.
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Affiliation(s)
| | | | | | | | | | | | - Xia Wu
- New Drug Research and Development Center, Guangdong Pharmaceutical University, Guangzhou 510006, China; (C.R.); (J.W.); (Y.T.); (M.G.); (J.G.); (Y.L.)
| | - Yifan Feng
- New Drug Research and Development Center, Guangdong Pharmaceutical University, Guangzhou 510006, China; (C.R.); (J.W.); (Y.T.); (M.G.); (J.G.); (Y.L.)
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Sohrabi C, Saberwal B, Lim WY, Tousoulis D, Ahsan S, Papageorgiou N. Heart Failure in Diabetes Mellitus: An Updated Review. Curr Pharm Des 2020; 26:5933-5952. [PMID: 33213313 DOI: 10.2174/1381612826666201118091659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus (DM) and heart failure (HF) are comorbid conditions associated with significant morbidity and mortality worldwide. Despite the availability of novel and effective therapeutic options and intensive glycaemic control strategies, mortality and hospitalisation rates continue to remain high and the incidence of HF persists. In this review, we described the impact of currently available glucose-lowering therapies in DM with a focus on HF clinical outcomes. Non-conventional modes of management and alternative pathophysiological mechanisms with the potential for therapeutic targeting are also discussed.
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Affiliation(s)
- Catrin Sohrabi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Bunny Saberwal
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Wei-Yao Lim
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Dimitris Tousoulis
- First Cardiology Department, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
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Sciannimanico S, Grimaldi F, Vescini F, De Pergola G, Iacoviello M, Licchelli B, Guastamacchia E, Giagulli VA, Triggiani V. Metformin: Up to Date. Endocr Metab Immune Disord Drug Targets 2020; 20:172-181. [PMID: 31670618 DOI: 10.2174/1871530319666190507125847] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Metformin is an oral hypoglycemic agent extensively used as first-line therapy for type 2 diabetes. It improves hyperglycemia by suppressing hepatic glucose production and increasing glucose uptake in muscles. Metformin improves insulin sensitivity and shows a beneficial effect on weight control. Besides its metabolic positive effects, Metformin has direct effects on inflammation and can have immunomodulatory and antineoplastic properties. AIM The aim of this narrative review was to summarize the up-to-date evidence from the current literature about the metabolic and non-metabolic effects of Metformin. METHODS We reviewed the current literature dealing with different effects and properties of Metformin and current recommendations about the use of this drug. We identified keywords and MeSH terms in Pubmed and the terms Metformin and type 2 diabetes, type 1 diabetes, pregnancy, heart failure, PCOS, etc, were searched, selecting only significant original articles and review in English, in particular of the last five years. CONCLUSION Even if many new effective hypoglycemic agents have been launched in the market in the last few years, Metformin would always keep a place in the treatment of type 2 diabetes and its comorbidities because of its multiple positive effects and low cost.
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Affiliation(s)
| | - Franco Grimaldi
- Endocrinology and Metabolism Unit, University Hospital of Udine, Udine, Italy
| | - Fabio Vescini
- Endocrinology and Metabolism Unit, University Hospital of Udine, Udine, Italy
| | - Giovanni De Pergola
- Clinical Nutrition Unit, Medical Oncology, Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", School of Medicine, Bari, Italy
| | - Massimo Iacoviello
- University Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari, Italy
| | - Brunella Licchelli
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari "Aldo Moro", School of Medicine, Bari, Italy
| | - Edoardo Guastamacchia
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari "Aldo Moro", School of Medicine, Bari, Italy
| | - Vito A Giagulli
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari "Aldo Moro", School of Medicine, Bari, Italy
| | - Vincenzo Triggiani
- Interdisciplinary Department of Medicine, Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, University of Bari "Aldo Moro", School of Medicine, Bari, Italy
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25
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Peralta S, Pinto M, Arguello T, Garcia S, Diaz F, Moraes CT. Metformin delays neurological symptom onset in a mouse model of neuronal complex I deficiency. JCI Insight 2020; 5:141183. [PMID: 33148885 PMCID: PMC7710273 DOI: 10.1172/jci.insight.141183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/21/2020] [Indexed: 12/24/2022] Open
Abstract
Complex I (also known as NADH-ubiquinone oxidoreductase) deficiency is the most frequent mitochondrial disorder present in childhood. NADH-ubiquinone oxidoreductase iron-sulfur protein 3 (NDUFS3) is a catalytic subunit of the mitochondrial complex I; NDUFS3 is conserved from bacteria and essential for complex I function. Mutations affecting complex I, including in the Ndufs3 gene, cause fatal neurodegenerative diseases, such as Leigh syndrome. No treatment is available for these conditions. We developed and performed a detailed molecular characterization of a neuron-specific Ndufs3 conditional KO mouse model. We showed that deletion of Ndufs3 in forebrain neurons reduced complex I activity, altered brain energy metabolism, and increased locomotor activity with impaired motor coordination, balance, and stereotyped behavior. Metabolomics analyses showed an increase of glycolysis intermediates, suggesting an adaptive response to the complex I defect. Administration of metformin to these mice delayed the onset of the neurological symptoms but not of neuronal loss. This improvement was likely related to enhancement of glucose uptake and utilization, which are known effects of metformin in the brain. Despite reports that metformin inhibits complex I activity, our findings did not show worsening a complex I defect nor increases in lactic acid, suggesting that metformin should be further evaluated for use in patients with mitochondrial encephalopathies. Metformin delays onset of mitochondrial encephalopathy in a CNS model of mitochondrial oxidative phosphorylation defect.
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Affiliation(s)
| | | | | | | | | | - Carlos T Moraes
- Department of Neurology and.,Department of Cell Biology, Miller School of Medicine, University of Miami, Miami, Florida, USA
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26
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Hasan SS, Kow CS, Bain A, Kavanagh S, Merchant HA, Hadi MA. Pharmacotherapeutic considerations for the management of diabetes mellitus among hospitalized COVID-19 patients. Expert Opin Pharmacother 2020; 22:229-240. [PMID: 33054481 DOI: 10.1080/14656566.2020.1837114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Diabetes mellitus is one of the most prevalent comorbidities identified in patients with coronavirus disease 2019 (COVID-19). This article aims to discuss the pharmacotherapeutic considerations for the management of diabetes in hospitalized patients with COVID-19. AREAS COVERED We discussed various aspects of pharmacotherapeutic management in hospitalized patients with COVID-19: (i) susceptibility and severity of COVID-19 among individuals with diabetes, (ii) glycemic goals for hospitalized patients with COVID-19 and concurrent diabetes, (iii) pharmacological treatment considerations for hospitalized patients with COVID-19 and concurrent diabetes. EXPERT OPINION The glycemic goals in patients with COVID-19 and concurrent type 1 (T1DM) or type 2 diabetes (T2DM) are to avoid disruption of stable metabolic state, maintain optimal glycemic control, and prevent adverse glycemic events. Patients with T1DM require insulin therapy at all times to prevent ketosis. The management strategies for patients with T2DM include temporary discontinuation of certain oral antidiabetic agents and consideration for insulin therapy. Patients with T2DM who are relatively stable and able to eat regularly may continue with oral antidiabetic agents if glycemic control is satisfactory. Hyperglycemia may develop in patients with systemic corticosteroid treatment and should be managed upon accordingly.
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Affiliation(s)
| | - Chia Siang Kow
- School of Postgraduate Studies, International Medical University , Kuala Lumpur, Malaysia
| | - Amie Bain
- Department of Pharmacy, University of Huddersfield , Huddersfield, UK.,Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
| | - Sallianne Kavanagh
- Department of Pharmacy, University of Huddersfield , Huddersfield, UK.,Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
| | - Hamid A Merchant
- Department of Pharmacy, University of Huddersfield , Huddersfield, UK
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27
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Pietraszek A. Cardiovascular Effects of Hypoglycemic Agents in Diabetes Mellitus. Curr Drug Saf 2020; 16:32-51. [PMID: 32881674 DOI: 10.2174/1574886315666200902154736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/01/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite substantial improvements over the years, diabetes mellitus is still associated with cardiovascular disease, heart failure, and excess mortality. OBJECTIVE The objective of this article is to examine existing data on the reduction of cardiovascular morbidity and mortality in diabetes. Control of glycemia, lipid levels, and blood pressure are described in brief. The main scope of this article is, however, to review the glucose-independent cardiovascular effect of antidiabetic pharmacological agents (mainly other than insulin). METHODS The article is a narrative review based on recently published reviews and meta-analyses complemented with data from individual trials, when relevant. RESULTS AND DISCUSSION Older data suggest a cardioprotective role of metformin (an inexpensive and safe drug); a role to date not convincingly challenged. The cardiovascular effects of thiazolidinediones, sulphonylurea, and glinides are debatable. Recent large-scale cardiovascular outcome trials suggest a neutral profile of dipeptidyl peptidase 4 inhibitors, yet provide compelling evidence of cardioprotective effects of glucagon-like 1 receptor antagonists and sodium-glucose transporter 2 inhibitors. CONCLUSION Metformin may have a role in primary and secondary prevention of cardiovascular disease; glucagon-like 1 receptor antagonists and sodium-glucose co-transporter 2 inhibitors play a role in secondary prevention of atherosclerotic cardiovascular disease. Sodium-glucose transporter 2 inhibitors have a role to play in both primary and secondary prevention of heart failure; yet, they carry a small risk of the potentially dangerous adverse effect, euglycemic diabetic ketoacidosis.
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Affiliation(s)
- Anna Pietraszek
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Aalborg, Denmark
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28
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Goonoo MS, Morris R, Raithatha A, Creagh F. Metformin-associated lactic acidosis: reinforcing learning points. BMJ Case Rep 2020; 13:e235608. [PMID: 32878828 PMCID: PMC7470503 DOI: 10.1136/bcr-2020-235608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 11/03/2022] Open
Abstract
Metformin-associated lactic acidosis (MALA) carries a high mortality rate. It is seen in patients with type 2 diabetes on metformin or patients who attempt suicide with metformin overdose. We present the case of a man in his early 20s with type 2 diabetes, hypertension and hypothyroidism who presented with agitation, abdominal pain and vomiting after ingesting 50-60 g of metformin; he developed severe lactic acidosis (blood pH 6.93, bicarbonate 7.8 mEq/L, lactate 28.0 mEq/L). He was managed with intravenous 8.4% bicarbonate infusion and continuous venovenous haemodiafiltration. He also developed acute renal failure (ARF) requiring intermittent haemodialysis and continuous haemodiafiltration. MALA is uncommon and causes changes in different vital organs and even death. The primary goals of therapy are restoration of acid-base status and removal of metformin. Early renal replacement therapy for ARF can result in rapid reversal of the acidosis and good recovery, even with levels of lactate normally considered to be incompatible with survival.
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Affiliation(s)
- Mohummad Shaan Goonoo
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rebecca Morris
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ajay Raithatha
- Critical Care Department, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fionuala Creagh
- Diabetes and Endocrine Centre, Hadfield Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Metformin-Associated Lactic Acidosis Developed as a Result of a Suicidal Attempt. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:252-256. [PMID: 32617068 PMCID: PMC7326677 DOI: 10.14744/semb.2018.35582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/12/2018] [Indexed: 11/20/2022]
Abstract
Metformin is a biguanide group drug commonly used in the treatment of Type 2 DM. Even though Metformin- Associated Lactic Acidosis (MALA) is not seen very frequently, MALA has a high mortality rate. This case is presented to draw attention to efficiency of hemodialysis and CVVHDF tin the treatment of MALA. A 25-year-old female patient was brought to the emergency service with abdominal pain and confusion. In her detailed history, it was learned that she took 100 tablets of metformin (1000 mg per tablet). Hemodialysis initiated because of severe metabolic acidosis, elevation of blood urea and hyperkalemia were seen in laboratory results. After that, patient was intubated because of low Glasgow Coma Scale (GCS:3) and vasopressor agent were started due to hypotension. In the intensive care unit, blood glucose was seen 44 mg dl-1 and treated with 10% dextrose solution. CVVHDF treatment was started because of anuria and metabolic acidosis. Patient who underwent CVVHDF treatment for 12-days transferred to nephrology service on the 23rd day of the ICU admission with full consciousness and stabilized vitals. In conclusion, hemodialysis and CVVHDF should be the first treatment methods to be considered in patients with metformin-associated lactic acidosis. Renal replacement therapies, initiated rapidly and maintained for an adequate time period are promising in this high mortality rate cases.
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Shin H, Taghavifar S, Salehi S, Joyce P, Gholamrezanezhad A. Current comments on contrast media administration in patients with renal insufficiency. Clin Imaging 2020; 69:37-44. [PMID: 32652456 DOI: 10.1016/j.clinimag.2020.06.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 06/07/2020] [Accepted: 06/26/2020] [Indexed: 01/10/2023]
Abstract
Contrast media administration has been associated with complications such as nephropathy, cardiovascular morbidity, and neurovascular events, particularly in patients with renal insufficiency. This association has been questioned in recent studies. This review was performed to summarize the most current evidence on contrast induced nephropathy (CIN), contributing factors, and considerations in patients with renal insufficiency. The risk of CIN was over-estimated by the previous studies, due to a lack of control groups or presence of non-randomized control groups, which led to a selection bias. However, the thresholds associated with an increased risk of CIN are controversial and require risk-benefit analysis on an individual basis. Regarding the administration of contrast media (CM) in the emergency setting, the majority of studies suggested that CM exposure does not meaningfully increase the risk of acute kidney injury in critically ill patients (including trauma patients). Several strategies have been suggested to reduce the risk of CIN, including volume expansion to increase renal blood flow, sodium bicarbonate or N-acetylcysteine administration, and use of low-osmolal contrast media in end-stage renal disease.
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Affiliation(s)
- Heeseop Shin
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | | | - Sana Salehi
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA.
| | - Peter Joyce
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
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31
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Kow CS, Hasan SS. Metformin use amid coronavirus disease 2019 pandemic. J Med Virol 2020; 92:2401-2402. [PMID: 32470199 PMCID: PMC7283671 DOI: 10.1002/jmv.26090] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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32
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The Use of Metformin to Increase the Human Healthspan. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1260:319-332. [PMID: 32304040 DOI: 10.1007/978-3-030-42667-5_13] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Metformin is a safe, effective and useful drug for glucose management in patients with diabetes. However in recent years, more attention has been paid to the possibility of using metformin as an anti-aging drug. It was shown to significantly increase the lifespan in some model organisms and delay the onset of age-associated declines. The current review summarizes advances in clinical research on the potential role of metformin in the field of lifespan and healthspan extension. Growing amounts of evidence from clinical trials suggest that metformin can effectively reduce the risk of many age-related diseases and conditions, including cardiometabolic disorders, neurodegeneration, chronic inflammation and frailty. Metformin also holds promise as a drug that could be repurposed for chemoprevention or adjuvant therapy for certain types of cancer. Moreover, metformin induces autophagy by activation of AMPK and can thus be potentially used to promote heathspan by hormesis-like mechanisms. Although long-term intake of metformin is associated with low risk of adverse events, well-designed clinical trials are still required to uncover the potential use of this drug as a geroprotector.
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Gnesin F, Thuesen ACB, Kähler LKA, Madsbad S, Hemmingsen B. Metformin monotherapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2020; 6:CD012906. [PMID: 32501595 PMCID: PMC7386876 DOI: 10.1002/14651858.cd012906.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Worldwide, there is an increasing incidence of type 2 diabetes mellitus (T2DM). Metformin is still the recommended first-line glucose-lowering drug for people with T2DM. Despite this, the effects of metformin on patient-important outcomes are still not clarified. OBJECTIVES To assess the effects of metformin monotherapy in adults with T2DM. SEARCH METHODS We based our search on a systematic report from the Agency for Healthcare Research and Quality, and topped-up the search in CENTRAL, MEDLINE, Embase, WHO ICTRP, and ClinicalTrials.gov. Additionally, we searched the reference lists of included trials and systematic reviews, as well as health technology assessment reports and medical agencies. The date of the last search for all databases was 2 December 2019, except Embase (searched up 28 April 2017). SELECTION CRITERIA We included randomised controlled trials (RCTs) with at least one year's duration comparing metformin monotherapy with no intervention, behaviour changing interventions or other glucose-lowering drugs in adults with T2DM. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles/records, assessed risk of bias, and extracted outcome data independently. We resolved discrepancies by involvement of a third review author. For meta-analyses we used a random-effects model with investigation of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the overall certainty of the evidence by using the GRADE instrument. MAIN RESULTS We included 18 RCTs with multiple study arms (N = 10,680). The percentage of participants finishing the trials was approximately 58% in all groups. Treatment duration ranged from one to 10.7 years. We judged no trials to be at low risk of bias on all 'Risk of bias' domains. The main outcomes of interest were all-cause mortality, serious adverse events (SAEs), health-related quality of life (HRQoL), cardiovascular mortality (CVM), non-fatal myocardial infarction (NFMI), non-fatal stroke (NFS), and end-stage renal disease (ESRD). Two trials compared metformin (N = 370) with insulin (N = 454). Neither trial reported on all-cause mortality, SAE, CVM, NFMI, NFS or ESRD. One trial provided information on HRQoL but did not show a substantial difference between the interventions. Seven trials compared metformin with sulphonylureas. Four trials reported on all-cause mortality: in three trials no participant died, and in the remaining trial 31/1454 participants (2.1%) in the metformin group died compared with 31/1441 participants (2.2%) in the sulphonylurea group (very low-certainty evidence). Three trials reported on SAE: in two trials no SAE occurred (186 participants); in the other trial 331/1454 participants (22.8%) in the metformin group experienced a SAE compared with 308/1441 participants (21.4%) in the sulphonylurea group (very low-certainty evidence). Two trials reported on CVM: in one trial no CVM was observed and in the other trial 4/1441 participants (0.3%) in the metformin group died of cardiovascular reasons compared with 8/1447 participants (0.6%) in the sulphonylurea group (very low-certainty evidence). Three trials reported on NFMI: in two trials no NFMI occurred, and in the other trial 21/1454 participants (1.4%) in the metformin group experienced a NFMI compared with 15/1441 participants (1.0%) in the sulphonylurea group (very low-certainty evidence). One trial reported no NFS occurred (very low-certainty evidence). No trial reported on HRQoL or ESRD. Seven trials compared metformin with thiazolidinediones (very low-certainty evidence for all outcomes). Five trials reported on all-cause mortality: in two trials no participant died; the overall RR was 0.88, 95% CI 0.55 to 1.39; P = 0.57; 5 trials; 4402 participants). Four trials reported on SAE, the RR was 0,95, 95% CI 0.84 to 1.09; P = 0.49; 3208 participants. Four trials reported on CVM, the RR was 0.71, 95% CI 0.21 to 2.39; P = 0.58; 3211 participants. Three trial reported on NFMI: in two trials no NFMI occurred and in one trial 21/1454 participants (1.4%) in the metformin group experienced a NFMI compared with 25/1456 participants (1.7%) in the thiazolidinedione group. One trial reported no NFS occurred. No trial reported on HRQoL or ESRD. Three trials compared metformin with dipeptidyl peptidase-4 inhibitors (one trial each with saxagliptin, sitagliptin, vildagliptin with altogether 1977 participants). There was no substantial difference between the interventions for all-cause mortality, SAE, CVM, NFMI and NFS (very low-certainty evidence for all outcomes). One trial compared metformin with a glucagon-like peptide-1 analogue (very low-certainty evidence for all reported outcomes). There was no substantial difference between the interventions for all-cause mortality, CVM, NFMI and NFS. One or more SAEs were reported in 16/268 (6.0%) of the participants allocated to metformin compared with 35/539 (6.5%) of the participants allocated to a glucagon-like peptide-1 analogue. HRQoL or ESRD were not reported. One trial compared metformin with meglitinide and two trials compared metformin with no intervention. No deaths or SAEs occurred (very low-certainty evidence) no other patient-important outcomes were reported. No trial compared metformin with placebo or a behaviour changing interventions. Four ongoing trials with 5824 participants are likely to report one or more of our outcomes of interest and are estimated to be completed between 2018 and 2024. Furthermore, 24 trials with 2369 participants are awaiting assessment. AUTHORS' CONCLUSIONS There is no clear evidence whether metformin monotherapy compared with no intervention, behaviour changing interventions or other glucose-lowering drugs influences patient-important outcomes.
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Affiliation(s)
- Filip Gnesin
- Department of Endocrinology, Diabetes and Metabolism, Department 7652, Rigshospitalet, Copenhagen, Denmark
| | - Anne Cathrine Baun Thuesen
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Novo Nordisk Foundation Center for Basic Metabolic Research, Copenhagen, Denmark
| | | | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Bianca Hemmingsen
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Yu Q, Zhu JJ, Liu WX. Effect of continuous use of metformin on kidney function in diabetes patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. BMC Cardiovasc Disord 2020; 20:187. [PMID: 32316910 PMCID: PMC7175536 DOI: 10.1186/s12872-020-01474-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/12/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Diabetes patients presenting with ST-segment elevation myocardial infarction (STEMI) scheduled for primary percutaneous coronary intervention (PCI) have an increased risk of contrast induced-acute kidney injury (CI-AKI). The effects of continuous use of metformin on kidney function are still controversial in patients submitted to primary PCI. This study aimed to assess continuous metformin therapy on kidney function in diabetic patients undergoing coronary intervention. METHODS Two hundred eighty-four patients with metformin-treated diabetes, who underwent coronary intervention within 24 h for STEMI, were enrolled in the retrospective study. All the patients had estimated glomerular filtration rate (eGFR) of > 30 mL/min/1.73 m2. According to the physicians' decisions after admission, 119 patients continued metformin treatment after primary PCI, while 165 patients discontinued it > 48 h after the procedure. Serum creatinine was collected at admission and within 48 h post primary PCI to evaluate the incidence of CI-AKI. We performed a multiple logistic regression analysis to examine the determinants of CI-AKI. RESULTS No statistical difference in CI-AKI incidence between the continuous and the discontinuous metformin group (12.6%vs10.3%, p = 0.545). Multivariable logistic regression analysis indicated eGFR ≤60 ml/min/1.73 m2[p = 0.025, OR: 3.131; 95% CI (1.156-8.482)] and contrast volume [p = 0.002, OR: 1.010; 95% CI (1.004-1.016)] were predictive factors of CI-AKI. Metformin therapy was irrelevant to CI-AKI [p = 0.365, OR: 0.698; 95% CI (0.320-1.521)]. No case of lactic acidosis was found in this study. Besides, the study supported discontinuation of metformin was not beneficial for patients' blood glucose control after admission. CONCLUSIONS The study indicated that the metformin continuation after primary PCI for STEMI in diabetic patients with eGFR > 30 ml/min / 1.73 m2 did not increase the risk of CI-AKI.
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Affiliation(s)
- Qi Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
| | - Jia-Jia Zhu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
| | - Wen-Xian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
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Abad K, Kien C, Ganta K. A Unique Case of Metformin-associated Severe Lactic Acidosis Without Preexisting Renal Disease: Perspectives on Prolonged Dialysis and Education for Prevention. Cureus 2020; 12:e7564. [PMID: 32382466 PMCID: PMC7202579 DOI: 10.7759/cureus.7564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/06/2020] [Indexed: 11/05/2022] Open
Abstract
Metabolic acidosis is a common disorder defined by an imbalance in the body's acid-base balance. Identifying the cause of acidosis is critical for its management. We describe a case of acute renal failure with lactic acidosis in a 69-year-old man who was taking metformin for type 2 diabetes. The patient presented with decreased urine output after two weeks of intermittent nausea and vomiting. During this time, the patient had continued to take limited fluids and medication, including lisinopril and metformin. Physical exam on initial evaluation was remarkable only for hypertension and minimal abdominal tenderness. However, laboratory tests revealed a severe lactic acidosis and renal failure with hyperkalemia. The patient had normal renal function and a normal urine albumin level three weeks prior. Broad-spectrum antibiotics and sodium bicarbonate were administered, followed by hemodialysis. During hemodialysis, the patient became hemodynamically unstable, requiring vasopressors. Post-dialysis, the lactic acidosis worsened, prompting the initiation of additional prolonged dialysis during the first hospital day. After the second lengthy dialysis, the patient's condition improved significantly and he was discharged on hospital day 12, with the diagnosis of metformin-associated lactic acidosis (MALA) in the setting of acute tubular necrosis from gastrointestinal fluid loss accompanied by the continued use of an angiotensin-converting enzyme inhibitor. After discharge, his renal function returned to normal. Severe lactic acidosis from metformin is relatively rare. Metformin has a large volume of distribution and accumulates in erythrocytes and intestinal cells, resulting in less efficient removal with dialysis and rebound lactic acidosis. Prolonged dialysis may be necessary for MALA to improve outcomes. Identifying metformin levels may help in diagnosis and management. However, the means to Identify metformin levels are not widely available. Patients receiving metformin should be counseled to stop metformin and seek medical care in the setting of illnesses. This is particularly important given the frequency of metformin prescription and the common use of renin-angiotensin system blockade in patients with type 2 diabetes, which increases the risk of kidney dysfunction.
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Affiliation(s)
- Kashif Abad
- Nephrology, University of New Mexico, Albuquerque, USA
| | - Cassandra Kien
- Biological Sciences, Arizona State University, Tempe, USA
| | - Kavitha Ganta
- Nephrology, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, USA
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Mazurek M, Litak J, Kamieniak P, Kulesza B, Jonak K, Baj J, Grochowski C. Metformin as Potential Therapy for High-Grade Glioma. Cancers (Basel) 2020; 12:E210. [PMID: 31952173 PMCID: PMC7016983 DOI: 10.3390/cancers12010210] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 12/15/2022] Open
Abstract
Metformin (MET), 1,1-dimethylbiguanide hydrochloride, is a biguanide drug used as the first-line medication in the treatment of type 2 diabetes. The recent years have brought many observations showing metformin in its new role. The drug, commonly used in the therapy of diabetes, may also find application in the therapy of a vast variety of tumors. Its effectiveness has been demonstrated in colon, breast, prostate, pancreatic cancer, leukemia, melanoma, lung and endometrial carcinoma, as well as in gliomas. This is especially important in light of the poor options offered to patients in the case of high-grade gliomas, which include glioblastoma (GBM). A thorough understanding of the mechanism of action of metformin can make it possible to discover new drugs that could be used in neoplasm therapy.
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Affiliation(s)
- Marek Mazurek
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (M.M.); (J.L.); (P.K.); (B.K.)
| | - Jakub Litak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (M.M.); (J.L.); (P.K.); (B.K.)
- Department of Immunology, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland
| | - Piotr Kamieniak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (M.M.); (J.L.); (P.K.); (B.K.)
| | - Bartłomiej Kulesza
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Jaczewskiego 8, 20-954 Lublin, Poland; (M.M.); (J.L.); (P.K.); (B.K.)
| | - Katarzyna Jonak
- Department of Foregin Languages, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland;
| | - Jacek Baj
- Department of Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland;
| | - Cezary Grochowski
- Department of Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland;
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Huynh K, Baghdanian AH, Baghdanian AA, Sun DS, Kolli KP, Zagoria RJ. Updated guidelines for intravenous contrast use for CT and MRI. Emerg Radiol 2020; 27:115-126. [PMID: 31925592 DOI: 10.1007/s10140-020-01751-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/03/2020] [Indexed: 12/29/2022]
Abstract
Intravenous (IV) contrast material is used extensively for CT and MRI scans done in emergency departments (ED). Its use is essential to make many critical diagnoses in ED patients. While adverse reactions can occur, newer research has added to our knowledge of IV contrast media tolerance and safety leading to improved and more liberal guidelines for intravenous contrast use. The updated information described in this review article indicates how intravenous contrast can be used safely in more patients, more expeditiously and with fewer precautions than with prior guidelines. This review article explains the basis for the new recommendations for intravenous contrast material use and describes indicated precautions and preparations to avoid adverse reactions for iodinated agents used for CT and gadolinium agents for MRI.
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Affiliation(s)
- Kevin Huynh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Arthur H Baghdanian
- Department of Radiology, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Armonde A Baghdanian
- Department of Radiology, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Derek S Sun
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
| | - K Pallav Kolli
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA.
| | - Ronald J Zagoria
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, USA
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Kamel KS, Oh MS, Halperin ML. L-lactic acidosis: pathophysiology, classification, and causes; emphasis on biochemical and metabolic basis. Kidney Int 2020; 97:75-88. [DOI: 10.1016/j.kint.2019.08.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/01/2019] [Accepted: 08/20/2019] [Indexed: 11/30/2022]
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Studies on characteristics and anti-diabetic and -nephritic effects of polysaccharides isolated from Paecilomyces hepiali fermentation mycelium in db/db mice. Carbohydr Polym 2019; 232:115766. [PMID: 31952583 DOI: 10.1016/j.carbpol.2019.115766] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 01/14/2023]
Abstract
Type 2 diabetes mellitus plagues many people in China and the world, and its nephritis complication is the leading cause of death for patients. Paecilomyces hepiali contained various functional components, especially polysaccharides, which possesses well pharmacological activities. In this study, polysaccharide purified from Paecilomyces hepiali fermented mycelium entitled PHEA was obtained, and its structure was systemically characterized using fourier transform infrared spectroscopy (FT-IR) and nuclear magnetic resonance (NMR). In C57BL/KsJ (BKS).Cg-Dock7m +/+ Leprdb/JNju mice (db/db mice), via detecting the alternations on biochemical criterions, pathological indicators and protein expressions related to nuclear factor-E2-related factor 2 (Nrf2) and nuclear factor-κB (NF-κB) signaling in serum and/or tissues including muscle, liver and kidney after 8-week PHEA administration, the hypoglycemic, hypolipidemic, and anti-diabetic nephropathic activities of PHEA were confirmed. The purified P. Hepiali polysaccharide with the anti-diabetic and -nephritic properties was first reported in this study via regulating Nrf2-meadited NF-κB signaling in db/db mice.
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Kinoshita H, Yanai M, Ariyoshi K, Ando M, Tamura R. A patient with metformin-associated lactic acidosis successfully treated with continuous renal replacement therapy: a case report. J Med Case Rep 2019; 13:371. [PMID: 31842973 PMCID: PMC6916532 DOI: 10.1186/s13256-019-2311-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/13/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Metformin has been widely used as a first-line agent to treat type 2 diabetes mellitus. Lactic acidosis is a rare but serious adverse effect in patients treated with metformin. Recent studies noted a correlation between metformin accumulation and lactic acidosis. Continuous renal replacement therapy for the treatment of metformin-associated lactic acidosis has been documented in some case reports; however, there is currently no specific treatment for metformin-associated lactic acidosis. CASE PRESENTATION A 70-year-old Japanese woman with type 2 diabetes mellitus presented to an emergency room with metformin-associated lactic acidosis. She was found to be hypotensive and laboratory examinations revealed severe lactic acidosis: pH 6.618, partial pressure of carbon dioxide in arterial blood 17.3 mmHg, bicarbonate 1.7 mmol/L, and lactate 18 mmol/L. Severe acidemia persisted despite supportive care including intravenously administered fluids, sodium bicarbonate, antibiotics, and vasopressors. Continuous renal replacement therapy was initiated in our intensive care unit. After dialysis for 3 days, her lactate level and pH value completely normalized. The concentration of metformin detected was 77.5 mg/L, which is one of the highest in metformin-associated lactic acidosis successfully treated without overdose. CONCLUSIONS The present case had one of the highest metformin concentrations in metformin-associated lactic acidosis successfully treated with continuous renal replacement therapy, and serum metformin concentrations may be useful for the diagnosis of metformin-associated lactic acidosis. Metformin-associated lactic acidosis is a rare but important etiology of lactic acidosis. Continuous renal replacement therapy is advantageous for the treatment of hemodynamically unstable patients with metformin-associated lactic acidosis.
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Affiliation(s)
- Hiroki Kinoshita
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Machi Yanai
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, 2-1-1, Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Motozumi Ando
- Division of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Kobe Gakuin University, Kobe, Japan
| | - Ryo Tamura
- Department of Pharmacy, Kobe City Medical Center General Hospital, Kobe, Japan
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A Case of Linezolid Toxicity Presenting as a Sepsis Mimic. Case Rep Crit Care 2019; 2019:2157674. [PMID: 31929912 PMCID: PMC6935787 DOI: 10.1155/2019/2157674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/22/2019] [Accepted: 08/31/2019] [Indexed: 11/17/2022] Open
Abstract
Linezolid is an efficacious and well tolerated antimicrobial but can have serious adverse effects including myelo-suppression, serotonin syndrome, neuropathy, hypoglycemia, liver dysfunction, and lactic acidosis. The side effects are generally duration dependent; linezolid use is not recommended for more than 28 days. Case. A 59-year-old female presented with malaise, loss of appetite, and altered mentation. She had multiple medical comorbidities and required long-term anticoagulation with warfarin for venous thromboembolism. She had multiple medication allergies. Prior to admission, she was on linezolid for cellulitis of foot due to Methicillin-resistant Staphylococcus aureus (MRSA). On physical exam, she was drowsy and required endotracheal intubation for airway protection. Initial laboratory parameters showed lactic acidosis, thrombocytopenia, supra-therapeutic coagulation profile, low blood glucose, and transaminitis. Her altered mentation was due to hypoglycemia. The interaction with warfarin led to altered coagulation profile. She developed shock and vasopressors were initiated. Given her presentation, she was managed as severe sepsis. There were no active infectious foci attributing to decline of her clinical status. Linezolid was discontinued and she was managed with intravenous polymyxin B, aztreonam, and vancomycin. Her hemodynamic status improved within one day. She was extubated on Day 5 of her presentation. Her laboratory parameters showed gradual improvement over 12 days after discontinuation of linezolid. Retrospective evaluation revealed linezolid toxicity as possible cause of presentation. Linezolid toxicity can present as sepsis mimic and should be considered as a differential diagnosis while managing sepsis with other antimicrobial agents.
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Taub ES, Hoffman RS, Manini AF. Incidence and risk factors for hyperlactatemia in ED patients with acute metformin overdose. Am J Emerg Med 2019; 37:2205-2208. [PMID: 30967322 PMCID: PMC9881186 DOI: 10.1016/j.ajem.2019.03.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/22/2019] [Accepted: 03/22/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION The goals of this study are to describe clinical characteristics and risk factors for metabolic acidosis with hyperlactatemia in emergency department (ED) patients with acute metformin overdose. METHODS This was a secondary analysis of data from a retrospective observational cohort of adult ED patients presenting with acute drug overdose at two tertiary care hospitals over 5 years. The primary outcomes were: (1) hyperlactatemia, defined as a lactate concentration ≥ 2 mmol/L at any point during hospital admission and, (2) metformin associated lactic acidosis (MALA), defined as a lactate concentration ≥ 5 mmol/L and pH <7.35 at any point during hospital admission. RESULTS We screened 3739 acute overdoses; 2872 met eligibility, 56 self-reported metformin overdose (57% female, mean age 55.8). Of these, 39 had measured lactate values. There was a high incidence of hyperlactatemia (56.4%); MALA was less frequent (17.9%). There were no deaths. Low serum bicarbonate was an independent clinical risk factor for hyperlactatemia (adjusted p < 0.05). Acetaminophen co-exposure was an independent clinical risk factor for MALA (OR 24.40, 95% CI 1.6-376.4). CONCLUSIONS In ED patients with acute metformin overdose, initial hyperlactatemia is common but MALA is unusual. Acetaminophen co-exposure is a novel independent risk factor for the occurrence of MALA that deserves further investigation.
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Affiliation(s)
- Emily S Taub
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY, New York, USA.
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY, New York, USA.
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, NY, New York, USA.
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Duggan E, Chen Y. Glycemic Management in the Operating Room: Screening, Monitoring, Oral Hypoglycemics, and Insulin Therapy. Curr Diab Rep 2019; 19:134. [PMID: 31749027 DOI: 10.1007/s11892-019-1277-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW This review provides a literature update and practical outline for the management of diabetes and stress hyperglycemia for adult surgical patients in the pre- and intraoperative settings. RECENT FINDINGS Hyperglycemia in surgical patients has been associated with increased risk of complication in both diabetic and non-diabetic patients in the perioperative setting. While current recommended perioperative blood glucose target is < 180 mg/dL (10 mmol/L), optimal outcomes may require different treatment targets for diabetic versus non-diabetic patients. Hemoglobin A1C level is associated with elevated risk of hyperglycemia and adverse outcomes, but there is insufficient evidence to recommend routine preoperative testing or optimal values in elective surgical patients. Day of surgery blood glucose testing and treatment are recommended in the perioperative period, and anesthetic management includes appropriate patient selection for use of subcutaneous insulin, intravenous insulin infusions, and insulin pumps. Additionally, administration of both intravenous and perineural dexamethasone is associated with increased blood glucose levels and clinicians should consider the risk benefit ratio in surgical patients. For enhanced recovery after surgery protocols, further evidence is needed to support routine use of carbohydrate loading in diabetic patients. Optimal perioperative care includes screening at-risk patients, use of preoperative oral hypoglycemics and home insulin, anesthetic type and medication selection, blood glucose testing, and treatment for hyperglycemia in the operating room. Partnerships with surgery and endocrinology teams aid optimal postoperative management and discharge planning.
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Affiliation(s)
- Elizabeth Duggan
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30322, USA.
| | - York Chen
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30322, USA
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Topcu A, Balik G, Atak M, Mercantepe T, Uydu HA, Tumkaya L. An investigation of the effects of metformin on ovarian ischemia-reperfusion injury in rats. Eur J Pharmacol 2019; 865:172790. [PMID: 31730761 DOI: 10.1016/j.ejphar.2019.172790] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 01/08/2023]
Abstract
Damage to the ovaries or tissue torsion can significantly reduce the ovarian reserve and thus cause severe gynecological and hormonal deficiencies. The discovery of new agents is always needed in the treatment of this condition. Metformin (MET) has been shown to be beneficial in attenuating ovarian ischemia-reperfusion injury. Fifty-six female Sprague Dawley rats were divided into seven groups. Group 1 represented the control group (C), Group 2, the ischemia group (I), and Group 3, the ischemia/reperfusion group (I/R). Group 4, the ischemia (I)+250 group, and Group 5, the ischemia (I)+500 group, received 250 mg/kg and 500 mg/kg MET, respectively. Group 6, the ischemia/reperfusion (I/R)+250 group, and Group 7, the ischemia/reperfusion (I/R)+500 group, received 250 mg/kg and 500 mg/kg MET, respectively. Tissue malondialdehyde (MDA), glutathione (GSH), and tumor necrosis factor-alpha (TNF-α) levels in ovarian tissue increased following I/R, while estradiol (E2) levels decreased. Moreover, infiltration and diffuse edematous areas were observed in addition to diffuse vascular congestion and hemorrhage findings. Caspase-3 and nuclear factor kappa B (NF-κβ) expression levels also increased. MDA and TNF-α concentrations decreased in the MET treatment groups, while GSH and E2 levels increased. The findings showed that I/R causes ovarian damage through the induction of oxidative stress, inflammation, and apoptosis. However, MET application was effective in preventing damage in ovarian tissue by reducing levels of reactive oxygen species, proinflammatory cytokines, caspase-3 and NF-κβ.
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Affiliation(s)
- Atilla Topcu
- Recep Tayyip Erdogan University, Faculty of Medicine, Department of Pharmacology, 53100, Rize, Turkey.
| | - Gulsah Balik
- Recep Tayyip Erdogan University, Faculty of Medicine, Department of Gynecology and Obstetrics, 53100, Rize, Turkey
| | - Mehtap Atak
- Recep Tayyip Erdogan University, Faculty of Medicine, Department of Medical Biochemistry, 53100, Rize, Turkey
| | - Tolga Mercantepe
- Recep Tayyip Erdogan University, Faculty of Medicine, Department of Histology and Embryology, 53100, Rize, Turkey
| | - Huseyin Avni Uydu
- Recep Tayyip Erdogan University, Faculty of Medicine, Department of Medical Biochemistry, 53100, Rize, Turkey
| | - Levent Tumkaya
- Recep Tayyip Erdogan University, Faculty of Medicine, Department of Histology and Embryology, 53100, Rize, Turkey
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Manoj Kumar RM, Narayanan NK, Raghunath KJ, Rajagopalan S. Composite Pheochromocytoma Presenting as Severe Lactic Acidosis and Back Pain: A Case Report. Indian J Nephrol 2019; 29:353-356. [PMID: 31571743 PMCID: PMC6755925 DOI: 10.4103/ijn.ijn_67_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pheochromocytoma is a rare, catecholamine secreting tumor arising from chromaffin cells. Presentation of this tumor is highly variable, the most common being hypertension, tachycardia, sweating, and headache. Lactic acidosis and back pain are rare complications of this tumor. We report a 51-year-old gentleman with composite pheochromocytoma, which is rarer than pheochromocytoma, presenting as severe back pain and lactic acidosis.
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Affiliation(s)
- R Mathi Manoj Kumar
- Department of Medicine, Apollo Hospital, Greams Lane, Chennai, Tamil Nadu, India
| | - N K Narayanan
- Department of Endocrinology, Apollo Hospital, Greams Lane, Chennai, Tamil Nadu, India
| | - K J Raghunath
- Department of Surgery, Apollo Hospital, Greams Lane, Chennai, Tamil Nadu, India
| | - S Rajagopalan
- Department of Nephrology, Apollo Hospital, Greams Lane, Chennai, Tamil Nadu, India
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Affiliation(s)
- James Flory
- Endocrinology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kasia Lipska
- Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut
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Metformin - Postmortem fatal and non-fatal reference concentrations in femoral blood and risk factors associated with fatal intoxications. Forensic Sci Int 2019; 303:109935. [PMID: 31491622 DOI: 10.1016/j.forsciint.2019.109935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/05/2019] [Accepted: 08/21/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND & OBJECTIVES To improve the interpretation of fatal intoxications by establishing fatal and non-fatal reference concentrations of metformin in postmortem femoral blood and to further evaluate risk factors associated with fatal metformin intoxication. METHODS All forensic autopsies in Sweden where metformin was detected in femoral blood 2011-2016 were identified in the National Board of Forensic Medicine databases (NFMD). The cases were classified as single substance intoxications, A (n = 22), multiple substance intoxications, B (N = 7) and postmortem controls, C (N = 13). The control group consisted of cases where metformin was detected, but the cause of death excluded the incapacitation by metformin or other substances. Strict inclusion criteria were used, and all postmortem cases were assessed by two independent reviewers. All other cases where the inclusion criteria of groups A-C where not met formed group O (N = 78). The forensic findings logged in the NFMD where linked to national registers whereby information on comorbidities, dispensed drugs and clinical data could be obtained. RESULTS The mean age was 66 ± 10 years in the total study population and did not differ between the groups. The proportion of men was 64% in group A, 71% in B, 77% in C and 74% in group O. The median values of metformin in group A (48.5 μg/g; range 13.0-210 μg/g) and B (21.0 μg/g; range 4.40-95.0 μg/g) were significantly (p < 0.001 and p = 0.015 respectively) higher than those of the control group C (2.30 μg/g ; range 0.70-21.0 μg/g). The median concentration of metformin in group A and B was also significantly higher than in group O (4.60 μg/g; range 0.64-54.0 μg/g) (p < 0.001 and p = 0.040 respectively). The results suggest that intoxication with metformin as a cause of death should be considered when the postmortem femoral blood level exceeds about 10 μg/g, although higher levels may be seen in postmortem in cases without incapacitation. The metformin intoxication was confirmed to be intentional in 23% (n = 5) of the single intoxications. Underlying factors identified as important for the remaining fatal metformin intoxications included living alone, any contraindication for the use of metformin, known alcohol abuse and a history of stroke or cardiovascular disease. CONCLUSIONS The reported post mortem femoral blood concentrations of metformin can hopefully contribute to a better interpretation of results in suspected poisonings and obscure cases. Living in a single household, history of cardiovascular disease and contraindications, predominantly alcohol abuse, were associated with fatal metformin intoxication.
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Abstract
Extracorporeal therapies have been used to remove toxins from the body for over 50 years and have a greater role than ever before in the treatment of poisonings. Improvements in technology have resulted in increased efficacy of removing drugs and other toxins with hemodialysis, and newer extracorporeal therapy modalities have expanded the role of extracorporeal supportive care of poisoned patients. However, despite these changes, for at least the past three decades the most frequently dialyzed poisons remain salicylates, toxic alcohols, and lithium; in addition, the extracorporeal treatment of choice for therapeutic removal of nearly all poisonings remains intermittent hemodialysis. For the clinician, consideration of extracorporeal therapy in the treatment of a poisoning depends upon the characteristics of toxins amenable to extracorporeal removal (e.g., molecular mass, volume of distribution, protein binding), choice of extracorporeal treatment modality for a given poisoning, and when the benefit of the procedure justifies additive risk. Given the relative rarity of poisonings treated with extracorporeal therapies, the level of evidence for extracorporeal treatment of poisoning is not robust; however, extracorporeal treatment of a number of individual toxins have been systematically reviewed within the current decade by the Extracorporeal Treatment in Poisoning workgroup, which has published treatment recommendations with an improved evidence base. Some of these recommendations are discussed, as well as management of a small number of relevant poisonings where extracorporeal therapy use may be considered.
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Affiliation(s)
- Joshua David King
- Division of Nephrology, University of Maryland, Baltimore, Maryland; .,Maryland Poison Center, Baltimore, Maryland
| | - Moritz H Kern
- Department of Medicine, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Bernard G Jaar
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and.,Nephrology Center of Maryland, Baltimore, Maryland
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Pasquel FJ, Fayfman M, Umpierrez GE. Debate on Insulin vs Non-insulin Use in the Hospital Setting-Is It Time to Revise the Guidelines for the Management of Inpatient Diabetes? Curr Diab Rep 2019; 19:65. [PMID: 31353426 DOI: 10.1007/s11892-019-1184-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Hyperglycemia contributes to a significant increase in morbidity, mortality, and healthcare costs in the hospital. Professional associations recommend insulin as the mainstay of diabetes therapy in the inpatient setting. The standard of care basal-bolus insulin regimen is a labor-intensive approach associated with a significant risk of iatrogenic hypoglycemia. This review summarizes recent evidence from observational studies and clinical trials suggesting that not all patients require treatment with complex insulin regimens. RECENT FINDINGS Evidence from clinical trials shows that incretin-based agents are effective in appropriately selected hospitalized patients and may be a safe alternative to complicated insulin regimens. Observational studies also show that older agents (i.e., metformin and sulfonylureas) are commonly used in the hospital, but there are few carefully designed studies addressing their efficacy. Therapy with dipeptidyl peptidase-4 (DPP-4) inhibitors, alone or in combination with basal insulin, may effectively control glucose levels in patients with mild to moderate hyperglycemia. Further studies with glucagon-like peptide-1 (GLP-1) receptor analogs and older oral agents are needed to confirm their safety in the hospital.
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Affiliation(s)
- Francisco J Pasquel
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Maya Fayfman
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Guillermo E Umpierrez
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
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Sorohan BM, Ismail G, Andronesi A, Micu G, Obrișcă B, Jurubiță R, Sinescu I, Baston C. A single-arm pilot study of metformin in patients with autosomal dominant polycystic kidney disease. BMC Nephrol 2019; 20:276. [PMID: 31337351 PMCID: PMC6651959 DOI: 10.1186/s12882-019-1463-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Metformin has shown promising results regarding cystogenesis inhibition in preclinical studies with autosomal dominant polycystic kidney disease (ADPKD) models. We designed a prospective, preliminary, single-arm study to evaluate the tolerability, safety and the effect of Metformin on kidney function and body mass index (BMI) in Romanian patients with ADPKD. Methods We enrolled 34 adult patients with ADPKD, chronic kidney disease (CKD) stages 1–5 not on dialysis and without diabetes mellitus. The primary endpoint was to assess the tolerability and safety of Metformin. The secondary endpoints evaluated changes in estimated glomerular filtration rate (eGFR), body mass index (BMI) and renal replacement therapy (RRT) necessity. Patients received an initial dose of Metformin of 500 mg/day within the first month that was increased to 1000 mg/day thereafter according to tolerability. Change in eGFR and BMI was expressed as mean difference with the corresponding 95% confidence intervals and as a percentage. For the primary endpoint, we included all 34 enrolled patients. To assess the secondary endpoint, intention-to-treat (ITT) and per-protocol (PP) analysis was performed. Results Sixteen patients out of 34 completed the follow-up period at 24 months. Eighteen patients developed adverse events and 63.6% of these events were gastrointestinal related. Nausea was the most common adverse event (17.6%). Two patients (5.8%) permanently discontinued medication due to adverse events. We recorded no case of hypoglycemia, lactic acidosis or death. Mean eGFR changed by − 1.57 ml/min/1.73m2 (95%CI:-22.28 to 19.14, P = 0.87) in ITT and by − 4.57 ml/min/1.73m2 (95%CI:-28.03 to 18.89, P = 0.69) in PP population. Mean BMI change was − 1.10 kg/m2 (95%CI:-3.22 to 1.02, P = 0.30) in ITT population and − 0.80 kg/m2 (95%CI:-3.27 to 1.67, P = 0.51) in PP analysis. Three patients (8.8%) needed RRT. Conclusions Metformin was well tolerated, had a good safety profile even in ADPKD patients with advanced CKD and it was not associated with change in eGFR or BMI across the follow-up period. Trial registration The study was retrospectively registered on https://www.isrctn.com (number ISRCTN 93749377); date registered: 02/25/2019.
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Affiliation(s)
- Bogdan Marian Sorohan
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Gener Ismail
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. .,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania.
| | - Andreea Andronesi
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Georgia Micu
- Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Bogdan Obrișcă
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Roxana Jurubiță
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Nephrology Department, Fundeni Clinical Institute, Fundeni Street No. 258, ZIP Code 022328, District No.2, Bucharest, Romania
| | - Ioanel Sinescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Cătălin Baston
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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