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Fonseca RID, Menezes LRA, Santana-Filho AP, Schiefer EM, Pecoits-Filho R, Stinghen AEM, Sassaki GL. Untargeted plasma 1H NMR-based metabolomic profiling in different stages of chronic kidney disease. J Pharm Biomed Anal 2023; 229:115339. [PMID: 36963247 DOI: 10.1016/j.jpba.2023.115339] [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: 01/25/2023] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/13/2023]
Abstract
Chronic kidney disease (CKD) is a serious public health issue affecting thousands of people worldwide. CKD diagnosis is usually made by Estimated Glomerular Filtration Rate (eGFR) and albuminuria, which limit the knowledge of the mechanisms behind CKD progression. The aim of the present study was to identify changes in the metabolomic profile that occur as CKD advances. In this sense, 77 plasma samples from patients with CDK were evaluated by 1D and 2D Nuclear Magnetic Resonance Spectroscopy (NMR). The NMR data showed significant changes in the metabolomic profile of CKD patients and the control group. Principal component analysis (PCA) clustered CKD and control patients into three distinct groups, control, stage 1 (G1)-stage 4 (G4) and stage 5 (G5). Lactate, glucose, acetate and creatinine were responsible for discriminating the control group from all the others CKD stages. Valine, alanine, glucose, creatinine, glutamate and lactate were responsible for the clustering of G1-G4 stages. G5 was discriminated by calcium ethylenediamine tetraacetic acid, magnesium ethylenediamine tetraacetic acid, creatinine, betaine/choline/trimethylamine N-oxide (TMAO), lactate and acetate. CKD G5 plasma pool which was submitted in MetaboAnalyst 4.0 platform (MetPA) analysis and showed 13 metabolic pathways involved in CKD physiopathology. Metabolic changes associated with glycolysis and gluconeogenesis allowed discriminating between CKD and control patients. The determination of involved molecules in TMAO generation in G5 suggests an important role in this uremic toxin linked to CKD and cardiovascular diseases. The aforementioned results propose the feasibility of metabolic assessment of CKD by NMR during treatment and disease progression.
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Affiliation(s)
| | | | | | - Elberth Manfron Schiefer
- Universidade Tecnológica Federal do Paraná, Av. Sete de Setembro, 3165, Curitiba 80230-901, Brazil
| | - Roberto Pecoits-Filho
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba CEP 80215-901, Brazil
| | | | - Guilherme Lanzi Sassaki
- Department of Biochemistry and Molecular Biology, Universidade Federal do Paraná, Curitiba 80050-540, Brazil.
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2
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Tamaki H, Tsushima H, Kachi N, Jimura F. Cardiac Dysfunction Due to Thiamine Deficiency after Hemodialysis for Biguanide-related Lactic Acidosis. Intern Med 2022; 61:2905-2909. [PMID: 35135918 PMCID: PMC9593142 DOI: 10.2169/internalmedicine.8697-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Biguanide is an ideal drug for the treatment of type 2 diabetes mellitus. When used appropriately, the incidence of lactic acidosis is reported to be very low. Risk factors associated with biguanide-related lactic acidosis include chronic kidney disease, congestive heart failure, alcohol use, severe dehydration, shock, hypoxic states, sepsis, and advanced age. We herein report a case of cardiac dysfunction due to thiamine deficiency after hemodialysis in a patient with suspected biguanide-related lactic acidosis. Patients who develop severe lactic acidosis while taking biguanides should be given a large dose of thiamine without delay, given the possibility of thiamine deficiency as a complication.
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Affiliation(s)
| | - Hideo Tsushima
- Department of Nephrology, Saiseikai Suita Hospital, Japan
| | - Naoki Kachi
- Department of Nephrology, Saiseikai Suita Hospital, Japan
| | - Fumie Jimura
- Department of Nephrology, Saiseikai Suita Hospital, Japan
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3
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Compliance with Prescription Guidelines for Glucose-Lowering Therapies According to Renal Function: Real-Life Study in Inpatients of Internal Medicine, Endocrinology and Cardiology Units. Medicina (B Aires) 2021; 57:medicina57121376. [PMID: 34946320 PMCID: PMC8704212 DOI: 10.3390/medicina57121376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 12/19/2022] Open
Abstract
Background and objectives: Renal failure is a contraindication for some glucose-lowering drugs and requires dosage adjustment for others, particularly biguanides, sulfonylureas, and inhibitors of dipeptidyl peptidase 4. In this study, we assessed adherence to prescription recommendations for glucose-lowering drugs according to renal function in hospitalized diabetic subjects. Materials and Methods: This prospective cohort study was carried out over a 2-year period in a university hospital. Glomerular filtration rate (GFR) was determined by averaging all measurements performed during hospitalization. Glucose-lowering drug dosages were analyzed according to the recommendations of the relevant medical societies. Results: In total, 2071 diabetic patients (53% hospitalized in cardiology units) were examined. GFR was <30 mL/min/1.73 m2 in 13.4% of these patients, 30–44 in 15.1%, 45–60 in 18.3%, and >60 in 53.3%. Inappropriate oral glucose-lowering treatments were administered to 273 (13.2%) patients, including 53 (2.6%) with a contraindication. In cardiology units, 53.1% and 14.3% of patients had GFRs of <60 and <30 mL/min/1.73 m2, respectively, and 179 (15.4%) patients had a contraindication or were prescribed an excessive dose of glucose-lowering drugs. Conclusions: We showed that the burden of inappropriate prescriptions is high in diabetic patients. Given the high number of patients receiving these medications, particularly in cardiology units, a search for potential adverse effects related to these drugs should be performed.
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Hanke N, Türk D, Selzer D, Ishiguro N, Ebner T, Wiebe S, Müller F, Stopfer P, Nock V, Lehr T. A Comprehensive Whole-Body Physiologically Based Pharmacokinetic Drug-Drug-Gene Interaction Model of Metformin and Cimetidine in Healthy Adults and Renally Impaired Individuals. Clin Pharmacokinet 2021; 59:1419-1431. [PMID: 32449077 PMCID: PMC7658088 DOI: 10.1007/s40262-020-00896-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Metformin is a widely prescribed antidiabetic BCS Class III drug (low permeability) that depends on active transport for its absorption and disposition. It is recommended by the US Food and Drug Administration as a clinical substrate of organic cation transporter 2/multidrug and toxin extrusion protein for drug–drug interaction studies. Cimetidine is a potent organic cation transporter 2/multidrug and toxin extrusion protein inhibitor. Objective The objective of this study was to provide mechanistic whole-body physiologically based pharmacokinetic models of metformin and cimetidine, built and evaluated to describe the metformin-SLC22A2 808G>T drug–gene interaction, the cimetidine-metformin drug–drug interaction, and the impact of renal impairment on metformin exposure. Methods Physiologically based pharmacokinetic models were developed in PK-Sim® (version 8.0). Thirty-nine clinical studies (dosing range 0.001–2550 mg), providing metformin plasma and urine data, positron emission tomography measurements of tissue concentrations, studies in organic cation transporter 2 polymorphic volunteers, drug–drug interaction studies with cimetidine, and data from patients in different stages of chronic kidney disease, were used to develop the metformin model. Twenty-seven clinical studies (dosing range 100–800 mg), reporting cimetidine plasma and urine concentrations, were used for the cimetidine model development. Results The established physiologically based pharmacokinetic models adequately describe the available clinical data, including the investigated drug–gene interaction, drug–drug interaction, and drug–drug–gene interaction studies, as well as the metformin exposure during renal impairment. All modeled drug–drug interaction area under the curve and maximum concentration ratios are within 1.5-fold of the observed ratios. The clinical data of renally impaired patients shows the expected increase in metformin exposure with declining kidney function, but also indicates counter-regulatory mechanisms in severe renal disease; these mechanisms were implemented into the model based on findings in preclinical species. Conclusions Whole-body physiologically based pharmacokinetic models of metformin and cimetidine were built and qualified for the prediction of metformin pharmacokinetics during drug–gene interaction, drug–drug interaction, and different stages of renal disease. The model files will be freely available in the Open Systems Pharmacology model repository. Current guidelines for metformin treatment of renally impaired patients should be reviewed to avoid overdosing in CKD3 and to allow metformin therapy of CKD4 patients. Electronic supplementary material The online version of this article (10.1007/s40262-020-00896-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina Hanke
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany
| | - Denise Türk
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany
| | - Dominik Selzer
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany
| | - Naoki Ishiguro
- Kobe Pharma Research Institute, Nippon Boehringer Ingelheim Co. Ltd., Kobe, Japan
| | - Thomas Ebner
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Sabrina Wiebe
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany.,Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Fabian Müller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany.,Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Peter Stopfer
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Valerie Nock
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Thorsten Lehr
- Clinical Pharmacy, Saarland University, Campus C2 2, 66123, Saarbrücken, Germany.
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5
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Grissi M, Boudot C, Assem M, Candellier A, Lando M, Poirot-Leclercq S, Boullier A, Bennis Y, Lenglet G, Avondo C, Lalau JD, Choukroun G, Massy ZA, Kamel S, Chillon JM, Hénaut L. Metformin prevents stroke damage in non-diabetic female mice with chronic kidney disease. Sci Rep 2021; 11:7464. [PMID: 33811249 PMCID: PMC8018962 DOI: 10.1038/s41598-021-86905-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 03/17/2021] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease (CKD) worsens ischemic stroke severity in both patients and animals. In mice, these poorer functional outcomes are associated with decreased brain activity of AMP-activated protein kinase (AMPK), a molecule that recently emerged as a potential therapeutic target for ischemic stroke. The antidiabetic drug metformin, a well-known activator of AMPK, has improved stroke outcomes in diabetic patients with normal renal function. We investigated whether chronic metformin pre-conditioning can rescue AMPK activity and prevent stroke damage in non-diabetic mice with CKD. Eight-week-old female C57BL/6J mice were assigned to CKD or SHAM groups. CKD was induced through right kidney cortical electrocautery, followed by left total nephrectomy. Mice were then allocated to receive metformin (200 mg/kg/day) or vehicle for 5 weeks until stroke induction by transient middle cerebral artery occlusion (tMCAO). The infarct volumes were lower in CKD mice exposed to metformin than in vehicle-treated CKD mice 24 h after tMCAO. Metformin pre-conditioning of CKD mice improved their neurological score, grip strength, and prehensile abilities. It also enhanced AMPK activation, reduced apoptosis, increased neuron survival and decreased microglia/macrophage M1 signature gene expression as well as CKD-induced activation of the canonical NF-κB pathway in the ischemic lesions of CKD mice.
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MESH Headings
- Adenylate Kinase/metabolism
- Animals
- Apoptosis/drug effects
- Body Weight
- Brain Infarction/blood
- Brain Infarction/complications
- Brain Infarction/drug therapy
- Brain Infarction/genetics
- Enzyme Activation/drug effects
- Female
- Gene Expression Regulation
- Gliosis/blood
- Gliosis/complications
- Gliosis/drug therapy
- Infarction, Middle Cerebral Artery/blood
- Infarction, Middle Cerebral Artery/complications
- Infarction, Middle Cerebral Artery/drug therapy
- Infarction, Middle Cerebral Artery/genetics
- Ischemic Preconditioning
- Macrophages/drug effects
- Macrophages/pathology
- Metformin/blood
- Metformin/pharmacology
- Metformin/therapeutic use
- Mice, Inbred C57BL
- Microglia/drug effects
- Microglia/pathology
- Models, Biological
- NF-kappa B/metabolism
- Neurons/drug effects
- Neurons/pathology
- Renal Insufficiency, Chronic/blood
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/drug therapy
- Renal Insufficiency, Chronic/genetics
- Stroke/drug therapy
- Stroke/genetics
- Stroke/prevention & control
- Mice
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Affiliation(s)
- Maria Grissi
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
| | - Cédric Boudot
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
| | - Maryam Assem
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Faculty of Medicine, University of Picardie Jules Verne, 80000, Amiens, France
- Division of Nephrology, Amiens University Hospital, 80054, Amiens, France
| | - Alexandre Candellier
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Faculty of Medicine, University of Picardie Jules Verne, 80000, Amiens, France
- Division of Nephrology, Amiens University Hospital, 80054, Amiens, France
| | - Mathilde Lando
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Faculty of Medicine, University of Picardie Jules Verne, 80000, Amiens, France
- Division of Nephrology, Amiens University Hospital, 80054, Amiens, France
| | - Sabrina Poirot-Leclercq
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
| | - Agnès Boullier
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Faculty of Medicine, University of Picardie Jules Verne, 80000, Amiens, France
- Department of Biochemistry, Amiens University Hospital, 80054, Amiens, France
| | - Youssef Bennis
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Department of Clinical Pharmacology, Amiens University Hospital, 80054, Amiens, France
| | - Gaëlle Lenglet
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
| | - Carine Avondo
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
| | - Jean-Daniel Lalau
- Faculty of Medicine, University of Picardie Jules Verne, 80000, Amiens, France
- Department of Endocrinology-Diabetology-Nutrition, Amiens University Hospital, 80054, Amiens, France
- UMR_I 01, PériTox, CURS, 80054, Amiens, France
| | - Gabriel Choukroun
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Faculty of Medicine, University of Picardie Jules Verne, 80000, Amiens, France
- Division of Nephrology, Amiens University Hospital, 80054, Amiens, France
| | - Ziad A Massy
- Department of Nephrology, Ambroise Paré University Hospital, APHP, 92104, Boulogne-Billancourt, France
- Inserm U1018-Team 5, CESP, UVSQ, University Paris Saclay, 94807, Villejuif, France
- University Versailles-Saint Quentin, University Paris-Saclay, 91190, Villejuif, France
| | - Saïd Kamel
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Department of Biochemistry, Amiens University Hospital, 80054, Amiens, France
- Faculty of Pharmacy, University of Picardie Jules Verne, 80000, Amiens, France
| | - Jean-Marc Chillon
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France
- Faculty of Pharmacy, University of Picardie Jules Verne, 80000, Amiens, France
- Direction of Clinical Research, Amiens University Hospital, 80054, Amiens, France
| | - Lucie Hénaut
- UR UPJV 7517, MP3CV, CURS, Université de Picardie Jules Verne, Avenue René Laennec, 80054, Amiens, France.
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Tuttle KR, McGill JB. Evidence-based treatment of hyperglycaemia with incretin therapies in patients with type 2 diabetes and advanced chronic kidney disease. Diabetes Obes Metab 2020; 22:1014-1023. [PMID: 32009296 PMCID: PMC7317405 DOI: 10.1111/dom.13986] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/20/2020] [Accepted: 01/30/2020] [Indexed: 01/14/2023]
Abstract
Type 2 diabetes is the leading cause of chronic kidney disease (CKD). The prevalence of CKD is growing in parallel with the rising number of patients with type 2 diabetes globally. At present, the optimal approach to glycaemic control in patients with type 2 diabetes and advanced CKD (categories 4 and 5) remains uncertain, as these patients were largely excluded from clinical trials of glucose-lowering therapies. Nonetheless, clinical trial data are available for the use of incretin therapies, dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, for patients with type 2 diabetes and advanced CKD. This review discusses the role of incretin therapies in the management of these patients. Because the presence of advanced CKD in patients with type 2 diabetes is associated with a markedly elevated risk of cardiovascular disease (CVD), treatment strategies must include the reduction of both CKD and CVD risks because death, particularly from cardiovascular causes, is more probable than progression to end-stage kidney disease. The management of hyperglycaemia is essential for good diabetes care even in advanced CKD. Current evidence supports an individualized approach to glycaemic management in patients with type 2 diabetes and advanced CKD, taking account of the needs of each patient, including the presence of co-morbidities and concomitant therapies. Although additional studies are needed to establish optimal strategies for glycaemic control in patients with type 2 diabetes and advanced CKD, treatment regimens with currently available pharmacotherapy can be individually tailored to meet the needs of this growing patient population.
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Affiliation(s)
- Katherine R. Tuttle
- Providence Medical Research CenterProvidence Health CareSpokaneWashington
- Division of Nephrology, Kidney Research Institute, and Institute of Translational Health SciencesUniversity of WashingtonSeattleWashington
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid ResearchWashington University School of MedicineSt. LouisMissouriUnited States
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7
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Chin SO, Ha IG, Rhee SY, Jeong SJ, Chon S, Kim SH, Ahn KJ, Baik SH, Park Y, Nam MS, Lee KW, Woo JT. Clinical Characteristics and Prevalence of Comorbidities according to Metformin Use in Korean Patients with Type 2 Diabetes. Int J Endocrinol 2020; 2020:9879517. [PMID: 32774367 PMCID: PMC7396103 DOI: 10.1155/2020/9879517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/15/2020] [Accepted: 06/30/2020] [Indexed: 12/28/2022] Open
Abstract
METHODS This cross-sectional study based on the Korean National Diabetes Program 2 registry used its baseline clinical data collected from seven participating university hospitals in Korea. Patients with no significant changes in their oral hypoglycemic agents and no diabetes-related complications within the year prior to participation were enrolled. Patients' clinical characteristics according to metformin use were analyzed. RESULTS Among 858 subjects included in the analyses, 706 were metformin users and 152 were nonmetformin users. Metformin users were significantly younger and had higher and glycated hemoglobin with significantly lower rates of accompanying microvascular complications such as retinopathy, cataracts, overt proteinuria, renal insufficiency, and peripheral neuropathy than nonusers. Meanwhile, there was a significantly lower prevalence of malignancy and depression among metformin users. These associations remained significant in multivariate analyses. The prevalence rate of macrovascular complications was not significantly different between the two groups. CONCLUSIONS There were significant differences with respect to clinical characteristics and comorbidity prevalence according to metformin use among Korean type 2 diabetes patients. Long-term follow-up of these patients is necessary to observe how this difference will affect clinical outcomes for these patients.
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Affiliation(s)
- Sang Ouk Chin
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - In Gyoon Ha
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sang Youl Rhee
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Su Jin Jeong
- Statistics Support Department, Kyung Hee University, Medical Center Science Research Institute, Seoul, Republic of Korea
| | - Suk Chon
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sung Hoon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Cheil General Hospital and Women's Healthcare Center, College of Medicine, Dankook University, Yongin, Republic of Korea
| | - Kyu Jeung Ahn
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sei Hyun Baik
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Yongsoo Park
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Moon Suk Nam
- Department of Internal Medicine, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Kwan Woo Lee
- Department of Endocrinology and Metabolism, College of Medicine, Ajou University, Suwon, Republic of Korea
| | - Jeong Taek Woo
- Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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8
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Stevens A, Hamel J, Toure A, Hadjadj S, Boels D. Metformin overdose: A serious iatrogenic complication—Western France Poison Control Centre Data Analysis. Basic Clin Pharmacol Toxicol 2019; 125:466-473. [DOI: 10.1111/bcpt.13273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/06/2019] [Indexed: 12/31/2022]
Affiliation(s)
| | - Jean‐François Hamel
- Representative of Clinical Research and Innovation Angers University Hospital Angers France
| | - Ali Toure
- Poison Control Centre Angers University Hospital Angers France
| | - Samy Hadjadj
- Department of Endocrinology and Diabetology Nantes University Hospital Nantes France
| | - David Boels
- Poison Control Centre Angers University Hospital Angers France
- Department of Pharmacology and Toxicology Nantes University Hospital Nantes France
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9
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Ermini G, Tosetti C, Zocchi D, Mandreoli M, Caletti MT, Marchesini G. Type 2 diabetes treatment and progression of chronic kidney disease in Italian family practice. J Endocrinol Invest 2019; 42:787-796. [PMID: 30465248 DOI: 10.1007/s40618-018-0983-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
AIMS Progressive chronic kidney disease represents a dreadful complication of type 2 diabetes mellitus (T2DM). We tested the pattern of use and the renal effects of old glucose-lowering drugs in T2DM patients cared for by Italian general practitioners (GPs). METHODS Data of 2606 T2DM patients were extracted from the databases of GPs, who do not have access to the most recent glucose-lowering drugs in Italy. The rate of kidney function decline was calculated by CKD-EPIcr, based on two consecutive creatinine values. RESULTS Metformin was used in 55% of cases, either alone or with sulfonylureas/repaglinide, across the whole spectrum of CKD (from 66% in stage G1 to only 8% in G4). Sulfonylurea use peaked at 21-22% in stage G2-G3a, whereas repaglinide use significantly increased from 8% in G1 to 22% in G4. The median rate of CKD decline was - 1.64 mL/min/1.73 m2 per year; it was higher in G1 (- 3.22 per year) and progressively lower with CKD severity. 826 cases (31.7%) were classified as fast progressors (eGFR decline more negative than - 5 mL/min/1.73 m2 per year). The risk of fast progressing CKD was associated with increasing BMI, albuminuria, and sulfonylurea use, alone (OR, 1.47; 95% confidence interval, 1.16-1.85), or in association with metformin (OR, 1.40; 95% CI 1.04-1.88). No associations were demonstrated for metformin, cardiovascular and lipid lowering drug use. CONCLUSION In the setting of Italian family practice, sulfonylurea use is associated with progressive CKD in patients with T2DM. Metformin, at doses progressively reduced according to CKD stages, as recommended by guidelines, is not associated with fast progression.
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Affiliation(s)
- G Ermini
- Section of the Italian College of General Practitioners and Primary Care, S.Orsola-Malpighi Hospital, "Alma Mater" University, 9, Via Massarenti, 40138, Bologna, Italy.
| | - C Tosetti
- Section of the Italian College of General Practitioners and Primary Care, S.Orsola-Malpighi Hospital, "Alma Mater" University, 9, Via Massarenti, 40138, Bologna, Italy
| | - D Zocchi
- Section of the Italian College of General Practitioners and Primary Care, S.Orsola-Malpighi Hospital, "Alma Mater" University, 9, Via Massarenti, 40138, Bologna, Italy
| | - M Mandreoli
- Nephrology and Dialysis Unit, S. Maria della Scaletta Hospital, Imola, Bologna, Italy
| | - M T Caletti
- Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater" University, Bologna, Italy
| | - G Marchesini
- Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater" University, Bologna, Italy
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10
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Raschi E, Mazzotti A, Poluzzi E, De Ponti F, Marchesini G. Pharmacotherapy of type 2 diabetes in patients with chronic liver disease: focus on nonalcoholic fatty liver disease. Expert Opin Pharmacother 2018; 19:1903-1914. [PMID: 30299993 DOI: 10.1080/14656566.2018.1531126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pharmacotherapy used to treat type 2 diabetes mellitus (T2DM) is facing a paradigm shift in clinical practice with recent cardiovascular (CV) outcome trials having a substantial impact on drug prescription with treatment having a more tailored approach. In patients with T2DM, the issue of chronic liver disease is multifaceted. However, a clinical evidence is emerging on the beneficial effect of antidiabetic medications on nonalcoholic fatty liver disease (NAFLD). AREAS COVERED The authors provide a synopsis on the current and upcoming pharmacotherapy for NAFLD, including the challenges with their development, focusing on drugs for T2DM. Clinical data on the potential benefits and safety issues are assessed with the aim of proposing an individualized algorithm for patient management. Both MEDLINE and ClinicalTrials.Gov are used to derive the relevant information. EXPERT OPINION Considering the pivotal role of insulin resistance in NAFLD, insulin sensitizers should be the treatment of choice. Accordingly, pioglitazone is the only drug with a significant effect on liver fibrosis, the driver of disease progression and long-term outcome. Among new glucose-lowering drugs, glucagon-like-peptide 1 receptor agonists or sodium-glucose cotransporter type 2 inhibitors have shown positive effects in phase II studies and are qualifying as potential candidates for NAFLD treatment in diabetes.
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Affiliation(s)
- Emanuel Raschi
- a Pharmacology Unit, Department of Medical and Surgical Sciences , University of Bologna , Bologna , Italy
| | - Arianna Mazzotti
- b Unit of Metabolic Diseases & Clinical Dietetics, Department of Medical and Surgical Sciences , University of Bologna , Bologna , Italy
| | - Elisabetta Poluzzi
- a Pharmacology Unit, Department of Medical and Surgical Sciences , University of Bologna , Bologna , Italy
| | - Fabrizio De Ponti
- a Pharmacology Unit, Department of Medical and Surgical Sciences , University of Bologna , Bologna , Italy
| | - Giulio Marchesini
- b Unit of Metabolic Diseases & Clinical Dietetics, Department of Medical and Surgical Sciences , University of Bologna , Bologna , Italy
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11
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Lalau JD, Kajbaf F, Bennis Y, Hurtel-Lemaire AS, Belpaire F, De Broe ME. Metformin Treatment in Patients With Type 2 Diabetes and Chronic Kidney Disease Stages 3A, 3B, or 4. Diabetes Care 2018; 41:547-553. [PMID: 29305402 DOI: 10.2337/dc17-2231] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/11/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study was conducted to define a safe, effective dose regimen for metformin in moderate and severe chronic kidney disease (CKD; stages 3A/3B and 4, respectively), after the lifting of restrictions on metformin use in patients with diabetes with moderate-to-severe CKD in the absence of prospective safety and efficacy studies. RESEARCH DESIGN AND METHODS Three complementary studies were performed: 1) a dose-finding study in CKD stages 1-5, in which blood metformin concentrations were evaluated during a 1-week period after each dose increase; 2) a 4-month metformin treatment study for validating the optimal metformin dose as a function of the CKD stage (3A, 3B, and 4), with blood metformin, lactate, and HbA1c concentrations monitored monthly; and 3) an assessment of pharmacokinetic parameters after the administration of a single dose of metformin in steady-state CKD stages 3A, 3B, and 4. RESULTS First, in the dose-finding study, the appropriate daily dosing schedules were 1,500 mg (0.5 g in the morning [qam] +1 g in the evening [qpm]) in CKD stage 3A, 1,000 mg (0.5 g qam + 0.5 g qpm) in CKD stage 3B, and 500 mg (qam) in CKD stage 4. Second, after 4 months on these regimens, patients displayed stable metformin concentrations that never exceeded the generally accepted safe upper limit of 5.0 mg/L. Hyperlactatemia (>5 mmol/L) was absent (except in a patient with myocardial infarction), and HbA1c levels did not change. Third, there were no significant differences in pharmacokinetic parameters among the CKD stage groups. CONCLUSIONS Provided that the dose is adjusted for renal function, metformin treatment appears to be safe and still pharmacologically efficacious in moderate-to-severe CKD.
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Affiliation(s)
- Jean-Daniel Lalau
- Department of Endocrinology-Nutrition, Amiens University Medical Center, Amiens, France .,INSERM 1088, Université de Picardie Jules Verne, Amiens, France
| | - Farshad Kajbaf
- Department of Endocrinology-Nutrition, Amiens University Medical Center, Amiens, France.,INSERM 1088, Université de Picardie Jules Verne, Amiens, France
| | - Youssef Bennis
- Laboratoire de Pharmacologie Clinique, Amiens University Medical Center, Amiens, France
| | | | - Frans Belpaire
- Heymans Institute of Pharmacology, University of Ghent, Ghent, Belgium
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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12
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Affiliation(s)
- Lili Tong
- Department of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles, Torrance, California
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13
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Bell S, Farran B, McGurnaghan S, McCrimmon RJ, Leese GP, Petrie JR, McKeigue P, Sattar N, Wild S, McKnight J, Lindsay R, Colhoun HM, Looker H. Risk of acute kidney injury and survival in patients treated with Metformin: an observational cohort study. BMC Nephrol 2017; 18:163. [PMID: 28526011 PMCID: PMC5437411 DOI: 10.1186/s12882-017-0579-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/11/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Whether metformin precipitates lactic acidosis in patients with chronic kidney disease (CKD) remains under debate. We examined whether metformin use was associated with an increased risk of acute kidney injury (AKI) as a proxy for lactic acidosis and whether survival among those with AKI varied by metformin exposure. METHODS All individuals with type 2 diabetes and available prescribing data between 2004 and 2013 in Tayside, Scotland were included. The electronic health record for diabetes which includes issued prescriptions was linked to laboratory biochemistry, hospital admission, death register and Scottish Renal Registry data. AKI events were defined using the Kidney Disease Improving Global Outcomes criteria with a rise in serum creatinine of at least 26.5 μmol/l or a rise of greater than 150% from baseline for all hospital admissions. Cox Regression Analyses were used to examine whether person-time periods in which current metformin exposure occurred were associated with an increased rate of first AKI compared to unexposed periods. Cox regression was also used to compare 28 day survival rates following first AKI events in those exposed to metformin versus those not exposed. RESULTS Twenty-five thousand one-hundred fourty-eight patients were included with a total person-time of 126,904 person years. 4944 (19.7%) people had at least one episode of AKI during the study period. There were 32.4 cases of first AKI/1000pyrs in current metformin exposed person-time periods compared to 44.9 cases/1000pyrs in unexposed periods. After adjustment for age, sex, diabetes duration, calendar time, number of diabetes drugs and baseline renal function, current metformin use was not associated with AKI incidence, HR 0.94 (95% CI 0.87, 1.02, p = 0.15). Among those with incident AKI, being on metformin at admission was associated with a higher rate of survival at 28 days (HR 0.81, 95% CI 0.69, 0.94, p = 0.006) even after adjustment for age, sex, pre-admission eGFR, HbA1c and diabetes duration. CONCLUSIONS Contrary to common perceptions, we found no evidence that metformin increases incidence of AKI and was associated with higher 28 day survival following incident AKI.
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Affiliation(s)
- Samira Bell
- Renal Unit, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Bassam Farran
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Stuart McGurnaghan
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Rory J McCrimmon
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Graham P Leese
- Department of Medicine, University of Dundee, Dundee, UK
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Paul McKeigue
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Sarah Wild
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
| | - John McKnight
- Department of Medicine, Western General Hospital, Edinburgh, UK
| | - Robert Lindsay
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine University of Edinburgh, Edinburgh, UK
| | - Helen Looker
- Division of Population Health Sciences, School of Medicine, University of Dundee, Dundee, UK
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Boucaud-Maitre D, Ropers J, Porokhov B, Altman JJ, Bouhanick B, Doucet J, Girardin E, Kaloustian E, Lassmann Vague V, Emmerich J. Lactic acidosis: relationship between metformin levels, lactate concentration and mortality. Diabet Med 2016; 33:1536-1543. [PMID: 26882092 DOI: 10.1111/dme.13098] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 01/10/2016] [Accepted: 02/11/2016] [Indexed: 01/22/2023]
Abstract
AIM The role of metformin in lactic acidosis is regularly questioned. Arguments against a causal role for metformin in lactic acidosis occurrence are the lack of correlation between plasma metformin and lactate levels, as well as between metformin plasma levels and mortality. We aim to analyse these correlations in a large series of lactic acidosis cases recorded in the French nationwide pharmacovigilance database. METHODS All cases of lactic acidosis spontaneously reported between 1985 and October 2013 associated with metformin exposure were extracted from the pharmacovigilance database. We assessed the statistical correlations between prescribed daily doses of metformin, plasma concentrations of metformin and lactate, pH and plasma creatinine, as well as the relationship between mortality and these variables. RESULTS Seven hundred and twenty-seven cases of lactic acidosis were reported during the period. Metformin plasma concentration was documented for 260 patients, lactate plasma concentration for 556 patients, pH for 502 patients, creatinine for 397 patients and the vital outcome for 713 patients. Metformin plasma concentration, lactate concentration, pH and plasma creatinine were all correlated (P < 0.001). There were significant differences between surviving and deceased patients in terms of metformin plasma levels (25.2 vs. 37.4 mg/l, P = 0.002) and lactate concentrations (10.8 vs. 16.3 mmol/l, P < 0.001). Thirty per cent of patients died when metformin concentration was > 5 mg/l compared with 11% for patients with concentration < 5 mg/l (P = 0.003). CONCLUSIONS Our data suggest that metformin accumulation contributes to the pathogenesis and prognosis of lactic acidosis.
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Affiliation(s)
- D Boucaud-Maitre
- Department of Drugs in Cardiology, Endocrinology, Gynecology, Urology, Agence Nationale de Sécurité du Médicament et des Produits de Santé (ANSM), Saint-Denis, France.
| | - J Ropers
- Clinical Research Unit, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - B Porokhov
- Department of Drugs in Cardiology, Endocrinology, Gynecology, Urology, Agence Nationale de Sécurité du Médicament et des Produits de Santé (ANSM), Saint-Denis, France
| | - J-J Altman
- Department of Diabetology, Endocrinology-Nutrition, University Paris V, Paris, France
| | - B Bouhanick
- Department of Internal Medicine and Hypertension, University Hospital Rangueil, Toulouse, France
| | - J Doucet
- Internal Medicine, Gériatry and Therapeutics, Saint Julien Hospital, Rouen University Hospital, Rouen, France
| | - E Girardin
- Birth Control Centre, Saint Louis Hospital, Paris, France
| | - E Kaloustian
- Internal Medicine and Endocrinology, Cabinet, Lacroix Saint-Ouen, France
| | | | - J Emmerich
- Department of Drugs in Cardiology, Endocrinology, Gynecology, Urology, Agence Nationale de Sécurité du Médicament et des Produits de Santé (ANSM), Saint-Denis, France
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15
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Chang CH, Sakaguchi M, Dolin P. Epidemiology of lactic acidosis in type 2 diabetes patients with metformin in Japan. Pharmacoepidemiol Drug Saf 2016; 25:1196-1203. [PMID: 27221971 PMCID: PMC5089598 DOI: 10.1002/pds.4030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 04/12/2016] [Accepted: 04/25/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE To estimate the incidence of lactic acidosis (LA) and role of metformin in Japanese patients with type 2 diabetes mellitus (T2DM) treated with anti-diabetes drugs. METHODS This retrospective propensity score matched cohort study was conducted using the Japanese Medical Data Vision claims database. T2DM patients aged 18 or above who received diabetes drugs during January 2010 through August 2014 were identified. Cases of LA were identified based on reimbursement codes and confirmed by lactic acid test and subsequent treatment by hemodialysis or intravenous sodium bicarbonate. Poisson regression and Cox proportional hazard models were used to estimate the incidence and assess if metformin use was associated with increased risk of LA. RESULTS Thirty cases of LA were identified among 283 491 treated T2DM patients with 504 169 patient-years of follow-up. Crude incidence of LA was 5.95 per 100 000 patient-years. T2DM patients with chronic kidney disease (CKD) were seven-fold more likely to develop LA than those without CKD (adjusted hazard ratio (aHR), 7.33, 95%CI, 3.17-16.96). Use of metformin was not associated with risk of LA in the study population (aHR, 0.92, 95%CI, 0.33-2.55), and in the propensity score matched cohort (aHR, 0.90, 95%CI, 0.26-3.11). Similar findings were observed among diabetes patients with chronic liver disease (CLD) and CKD. The age-sex adjusted incidence rates in metformin users and non-users were 5.80 and 5.78 per 100 000 person-years, respectively (Incidence rate ratio, 1.00, p = 0.99). CONCLUSIONS This study found that use of metformin was not associated with increased risk of LA in diabetic patients including those with CKD or CLD. © 2016 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.
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Affiliation(s)
- Chia-Hsien Chang
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan.
| | - Motonobu Sakaguchi
- Takeda Development Center Japan, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Paul Dolin
- Takeda Development Centre Europe Ltd, London, United Kingdom
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16
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Muller C, Dimitrov Y, Imhoff O, Richter S, Ott J, Krummel T, Bazin-Kara D, Chantrel F, Hannedouche T. Oral antidiabetics use among diabetic type 2 patients with chronic kidney disease. Do nephrologists take account of recommendations? J Diabetes Complications 2016; 30:675-80. [PMID: 26900098 DOI: 10.1016/j.jdiacomp.2016.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/12/2016] [Accepted: 01/20/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is an increasing prevalence of diabetes type 2 and chronic kidney disease, challenging appropriate prescribing of oral anti-diabetic drugs (OADs). METHODS We have described the practice patterns of 13 nephrologists in 4 centers, in a cohort of 301 consecutive adult type 2 diabetic patients. Among oral anti-diabetic prescriptions, we have detailed drugs dosage for each subject, with 3 different formulae for estimating glomerular filtration rate (GFR) and its adequation according to the latest ERBP recommendations (2015). As individuals were mostly obese in this work, we also compare adequacy rates using both standard indexed CKD-EPI formula and CKD-EPI formula de-indexed from body surface area. RESULTS Using the CKD-EPI formula as the reference method for estimating GFR, 53.5% of patients were outside the recommendations, mostly for metformin (30% of the whole cohort) and for sitagliptin (17.9% of the whole cohort). With Cockcroft and Gault formula, 38.2% of persons were outside recommendations and 45.9% (p<0.001) with CKD-EPI de-indexed. Among individuals consulting a nephrologist for the first time (n=90), 61.1% were outside recommendations (p=0.1). Among those persons under diabetologist supervision (n=103), 63.1% were outside recommendations (p=0.09), and were taking significantly more often metformin and insulin. CONCLUSION We have found a substantial number of inadequate OAD prescriptions in type 2 diabetic patients with chronic kidney disease. The proportion of individuals outside guidelines was strongly affected by the method used for estimating GFR and by the type of practice, i.e., specialists versus general practitioners.
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Affiliation(s)
- Clotilde Muller
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France; School of Medicine, University of Strasbourg, Rue Kirschleger, 67000, Strasbourg, France; UMR 1109, Laboratoire Immunologie et Rhumatologie, Strasbourg, France.
| | - Yves Dimitrov
- Haguenau Hospital, Nephrology department, 64 Avenue du Pr Leriche, 67500, Haguenau, France
| | - Olivier Imhoff
- Clinique Ste Anne, Nephrology department, Rue Philippe Thyss, 67085, Strasbourg, France
| | - Sarah Richter
- Clinique Ste Anne, Nephrology department, Rue Philippe Thyss, 67085, Strasbourg, France
| | - Julien Ott
- Haguenau Hospital, Nephrology department, 64 Avenue du Pr Leriche, 67500, Haguenau, France
| | - Thierry Krummel
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Dorothée Bazin-Kara
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Francois Chantrel
- Mulhouse Hospital, Nephrology department, 20 Avenue du Dr René Laennec, 68100, Mulhouse, France
| | - Thierry Hannedouche
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France; School of Medicine, University of Strasbourg, Rue Kirschleger, 67000, Strasbourg, France
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Retrospective analysis of lactic acidosis-related parameters upon and after metformin discontinuation in patients with diabetes and chronic kidney disease. Int Urol Nephrol 2016; 48:1305-1312. [PMID: 27102431 DOI: 10.1007/s11255-016-1288-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/09/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE To investigate association between renal functions, lactic acid levels and acid-base balance in type 2 diabetes patients with chronic kidney disease under metformin treatment and after metformin discontinuation in a real-life setting. METHODS A total of 65 patients with diabetes (mean age 68.5 ± 8.9 years, 56.9 % females) in whom metformin treatment was discontinued due to reduced glomerular filtration rate (GFR) were included in this retrospective study. Data on patient demographics, metformin treatment and laboratory findings on the last day of metformin treatment and 2-3 weeks after metformin discontinuation including blood lactate and creatinine, estimated glomerular filtration rate (eGFR) and acid-base balance measurements in blood [pH, bicarbonate, base excess] were collected from medical records. The correlation of lactate levels with eGFR, blood pH and creatinine levels and changes in laboratory findings after metformin discontinuation were evaluated. RESULTS Before metformin discontinuation, hyperlactatemia was observed in 78.5 % of patients and metabolic acidosis in 36.9 % of patients, but none had lactic acidosis. Patients with normolactatemia and hyperlactatemia were similar in terms of metformin dosage and laboratory parameters. Lactate levels were not significantly correlated with serum creatinine (r = -0.14; p = 0.263) and eGFR (r = 0.11, p = 0.374). After metformin discontinuation, a significant decrease was observed in median lactate levels (from 2.20 to 1.85 mmol/L; p = 0.002). CONCLUSION In conclusion, our findings support the low risk of MALA among patients with mild-to-moderate renal impairment and the likelihood of metformin to be an innocent bystander without a pathogenic role in the lactic acidosis in most cases.
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Moioli A, Maresca B, Manzione A, Napoletano AM, Coclite D, Pirozzi N, Punzo G, Menè P. Metformin associated lactic acidosis (MALA): clinical profiling and management. J Nephrol 2016; 29:783-789. [PMID: 26800971 DOI: 10.1007/s40620-016-0267-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 01/09/2016] [Indexed: 12/20/2022]
Abstract
Metformin (MF) accumulation during acute kidney injury is associated with high anion gap lactic acidosis type B (MF-associated lactic acidosis, MALA), a serious medical condition leading to high mortality. Despite dose adjustment for renal failure, diabetic patients with chronic kidney disease (CKD) stage III-IV are at risk for rapid decline in renal function by whatever reason, so that MF toxicity might arise if the drug is not timely withdrawn. Sixteen consecutive patients were admitted to our Hospital's Emergency Department with clinical findings consistent with MALA. Fifteen had prior history of CKD, 60 % of them with GFR between 30 and 60 ml/min. Of these, 5 required mechanical ventilation and cardiovascular support; 3 promptly recovered renal function after rehydration, whereas 10 (62 %) required continuous veno-venous renal replacement treatment. SOFA and SAPS II scores were significantly related to the degree of lactic acidosis. In addition, lactate levels were relevant to therapeutic choices, since they were higher in dialyzed patients than in those on conservative treatment (11.92 mmol/l vs 5.7 mmol/l, p = 0.03). The overall death rate has been 31 %, with poorer prognosis for worse acidemia, as serum pH was significantly lower in non-survivors (pH 6.96 vs 7.16, p > 0.04). Our own data and a review of the literature suggest that aged, hemodynamically frail patients, with several comorbidities and CKD, are at greater risk of MALA, despite MF dosage adjustment. Moreover, renal replacement therapy rather than simple acidosis correction by administration of alkali seems the treatment of choice, based on eventual renal recovery and overall outcome.
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Affiliation(s)
- Alessandra Moioli
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Barbara Maresca
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Andrea Manzione
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | | | | | - Nicola Pirozzi
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Giorgio Punzo
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Paolo Menè
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy. .,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy. .,UOC Nefrologia, A.O. Sant'Andrea, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
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Betônico CCR, Titan SMO, Correa-Giannella MLC, Nery M, Queiroz M. Management of diabetes mellitus in individuals with chronic kidney disease: therapeutic perspectives and glycemic control. Clinics (Sao Paulo) 2016; 71:47-53. [PMID: 26872083 PMCID: PMC4732385 DOI: 10.6061/clinics/2016(01)08] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 12/16/2022] Open
Abstract
The purpose of this study was to evaluate the therapeutic options for diabetes treatment and their potential side effects, in addition to analyzing the risks and benefits of tight glycemic control in patients with diabetic kidney disease. For this review, a search was performed using several pre-defined keyword combinations and their equivalents: "diabetes kidney disease" and "renal failure" in combination with "diabetes treatment" and "oral antidiabetic drugs" or "oral hypoglycemic agents." The search was performed in PubMed, Endocrine Abstracts and the Cochrane Library from January 1980 up to January 2015. Diabetes treatment in patients with diabetic kidney disease is challenging, in part because of progression of renal failure-related changes in insulin signaling, glucose transport and metabolism, favoring both hyperglycemic peaks and hypoglycemia. Additionally, the decline in renal function impairs the clearance and metabolism of antidiabetic agents and insulin, frequently requiring reassessment of prescriptions. The management of hyperglycemia in patients with diabetic kidney disease is even more difficult, requiring adjustment of antidiabetic agents and insulin doses. The health team responsible for the follow-up of these patients should be vigilant and prepared to make such changes; however, unfortunately, there are few guidelines addressing the nuances of the management of this specific population.
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Affiliation(s)
- Carolina C R Betônico
- Universidade Oeste Paulista, Hospital Regional de Presidente Prudente, Divisão de Endocrinologia, Presidente Prudente/, SP, Brazil
| | - Silvia M O Titan
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Medicina Interna, Divisão de Nefrologia
| | | | - Márcia Nery
- Divisão de Endocrinologia, São Paulo/, SP, Brazil
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Becquemont L, Bauduceau B, Benattar-Zibi L, Al-Salameh A, Berrut G, Bertin P, Bucher S, Corruble E, Danchin N, Derumeaux G, Doucet J, Falissard B, Forette F, Hanon O, Pasquier F, Pinget M, Ourabah R, Piedvache C. Cardiovascular Drugs and Metformin Drug Dosage According to Renal Function in Non-Institutionalized Elderly Patients. Basic Clin Pharmacol Toxicol 2015; 118:468-73. [DOI: 10.1111/bcpt.12526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/30/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Laurent Becquemont
- Pharmacology Department; Faculty of Medicine Paris-Sud; University Paris-Sud; UMR 1184; CEA, DSV/iMETI; Division of Immuno-Virology; IDMIT, INSERM Center for Immunology of Viral Infections and Autoimmune Diseases; Assistance Publique-Hôpitaux de Paris, Hopital Bicêtre; Le Kremlin Bicêtre France
| | | | | | - Abdallah Al-Salameh
- Pharmacology Department; Faculty of Medicine Paris-Sud; University Paris-Sud; UMR 1184; CEA, DSV/iMETI; Division of Immuno-Virology; IDMIT, INSERM Center for Immunology of Viral Infections and Autoimmune Diseases; Assistance Publique-Hôpitaux de Paris, Hopital Bicêtre; Le Kremlin Bicêtre France
| | | | - Philippe Bertin
- Rheumatology Department; Limoges University Hospital; Limoges France
| | - Sophie Bucher
- General Practice Department; Faculty of Medicine Paris-Sud; University Paris-Sud; Le Kremlin-Bicêtre France
| | - Emmanuelle Corruble
- Department of Psychiatry; Faculty of Medicine Paris-Sud; INSERM U 669; University Paris-Sud; Bicêtre University Hospital; Assistance Publique-Hôpitaux de Paris; Le Kremlin Bicêtre France
| | | | - Geneviève Derumeaux
- Cardiovascular Functional Exploration; Louis Pradel Hospital, Hospices Civils de Lyon; Bron France
| | - Jean Doucet
- Internal Medicine, Geriatrics and Therapeutics; Saint Julien University Hospital; Rouen University; Rouen France
| | - Bruno Falissard
- Biostatistics Department; Faculty of Medicine Paris-Sud; INSERM U 669; University Paris-Sud; Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse; Le Kremlin-Bicêtre France
| | - Francoise Forette
- National Foundation of Gerontology; University Paris Descartes; Paris France
| | - Olivier Hanon
- Geriatrics Department; University Paris Descartes; Assistance Publique-Hôpitaux de Paris, Hôpital Broca; Paris France
| | | | - Michel Pinget
- Endocrinology, Diabetes and Diseases of Nutrition (Pôle NUDE); University Hospital of Strasbourg and the European Centre for the Study of Diabetes (CeeD); University of Strasbourg; Strasbourg France
| | - Rissane Ourabah
- General Practice Department; Faculty of Medicine Paris-Sud; University Paris-Sud; Le Kremlin-Bicêtre France
| | - Celine Piedvache
- Pharmacology Department; Faculty of Medicine Paris-Sud; University Paris-Sud; UMR 1184; CEA, DSV/iMETI; Division of Immuno-Virology; IDMIT, INSERM Center for Immunology of Viral Infections and Autoimmune Diseases; Assistance Publique-Hôpitaux de Paris, Hopital Bicêtre; Le Kremlin Bicêtre France
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21
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Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015; 30 Suppl 2:ii1-142. [PMID: 25940656 DOI: 10.1093/ndt/gfv100] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Lalau JD, Kajbaf F, Arnouts P, de Broe M. Mortality and metformin use in patients with advanced chronic kidney disease. Lancet Diabetes Endocrinol 2015; 3:680-1. [PMID: 26298570 DOI: 10.1016/s2213-8587(15)00285-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 07/22/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Jean-Daniel Lalau
- Department of Endocrinology-Nutrition, University Hospital, F-80054 Amiens, France; INSERM Unit 1088, University of Picardie Jules Verne, Amiens, France.
| | - Farshad Kajbaf
- Department of Endocrinology-Nutrition, University Hospital, F-80054 Amiens, France; INSERM Unit 1088, University of Picardie Jules Verne, Amiens, France
| | - Paul Arnouts
- Department of Nephrology-Hypertension, Sint Jozefziekenhuis, Turnhout, Belgium
| | - Marc de Broe
- Laboratory of Pathophysiology, University Hospital, Antwerpen, Belgium
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Abstract
Lactic acidosis occurs when lactate production exceeds its metabolism. There are many possible causes of lactic acidosis, and in any given patient, several causes may coexist. This Attending Rounds presents a case in point. Metformin's role in the pathogenesis of lactic acidosis in patients with diabetes mellitus is complex, as the present case illustrates. The treatment of lactic acidosis is controversial, except for the imperative to remedy its underlying cause. The use of sodium bicarbonate to treat the often alarming metabolic derangements may be quite efficacious in that regard but is of questionable benefit to patients. Renal replacement therapies (RRTs) have particular appeal in this setting for a variety of reasons, but their effect on clinical outcomes is untested.
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Affiliation(s)
- Lawrence S Weisberg
- Division of Nephrology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
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Scheen AJ. Metformin should not be contraindicated in patients with type 2 diabetes and mild to moderate renal impairment. ACTA ACUST UNITED AC 2015; 20:115. [PMID: 25827139 DOI: 10.1136/ebmed-2015-110184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, University of Liège, Liège, UK
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25
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Ommen ES, Xu L, O'Neill EA, Goldstein BJ, Kaufman KD, Engel SS. Comparison of treatment with sitagliptin or sulfonylurea in patients with type 2 diabetes mellitus and mild renal impairment: a post hoc analysis of clinical trials. Diabetes Ther 2015; 6:29-40. [PMID: 25633134 PMCID: PMC4374078 DOI: 10.1007/s13300-015-0098-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Impaired renal function is a major complication of type 2 diabetes mellitus (T2DM). Mild renal impairment is present in 38% of patients with T2DM and may impact choice of antihyperglycemic agent. Sulfonylureas and dipeptidyl peptidase-4 (DPP-4) inhibitors are commonly used to treat hyperglycemia in patients with T2DM and renal impairment. Although in general sulfonylurea use is associated with an increased risk of hypoglycemia and weight gain, while DPP-4 inhibitor use is associated with a low risk of hypoglycemia, and is weight neutral, the relative efficacy and tolerability of these agents in patients with mild renal impairment has not been evaluated. METHODS In a post hoc analysis, data from 1,211 subjects with T2DM and mild renal impairment (estimated glomerular filtration rates of 60 to <90 mL/min/1.73 m(2)), who completed 25 or 30 weeks of one of three double-blind clinical trials comparing the DPP-4 inhibitor sitagliptin 100 mg/day with sulfonylureas in titrated doses, were pooled. The analysis compared change from baseline in glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), body weight, incidence of symptomatic hypoglycemia and the percentages of subjects meeting a composite endpoint of HbA1c decrease >0.5% without symptomatic hypoglycemia or body weight gain between sitagliptin and sulfonylurea treatment groups. RESULTS HbA1c and FPG decreased similarly with sitagliptin or sulfonylurea. A lower incidence of hypoglycemia was observed with sitagliptin. Body weight decreased with sitagliptin but increased with sulfonylurea. A greater percentage of subjects treated with sitagliptin (41.1%) than treated with sulfonylurea (16.9%) achieved the composite endpoint of >0.5% HbA1c reduction with no symptomatic hypoglycemia or body weight gain. CONCLUSION In this analysis of subjects with T2DM and mild renal impairment, treatment with sitagliptin provided glycemic efficacy similar to sulfonylurea, with less hypoglycemia and with body weight loss compared to body weight gain seen with sulfonylurea. TRIAL REGISTRATIONS ClinicalTrials.gov #NCT00482079, #NCT00094770, #NCT00701090.
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26
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Stephen J, Anderson-Haag TL, Gustafson S, Snyder JJ, Kasiske BL, Israni AK. Metformin use in kidney transplant recipients in the United States: an observational study. Am J Nephrol 2015; 40:546-53. [PMID: 25613554 DOI: 10.1159/000370034] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 11/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Although metformin is contraindicated in patients with increased serum creatinine levels (≥1.5 mg/dl in men, ≥1.4 mg/dl in women) in the United States, its use has not been systematically examined in kidney transplant recipients. We aimed to determine the frequency of metformin use and its associations among kidney transplant recipients, and to assess allograft and patient survival associated with metformin use. METHODS In this retrospective cohort study, we linked Scientific Registry of Transplant Recipients data for all incident kidney transplants 2001-2012 and national pharmacy claims (n = 46,914). We compared recipients having one or more pharmacy claims for a metformin-containing product (n = 4,609) and recipients having one or more claims for a non-metformin glucose-lowering agent (n = 42,305). RESULTS On average, metformin claims were filled later after transplant and were associated with higher estimated glomerular filtration rates before the first claim. Median serum creatinine (mg/dl) levels before the first claim were lower in recipients with metformin claims than in those with non-metformin claims (1.3 [interquartile range 1.0-1.7] vs. 1.6 [1.2-2.5], respectively; p < 0.0001). Metformin was associated with lower adjusted hazards for living donor (0.55, 95% confidence interval 0.38-0.80; p = 0.002) and deceased donor (0.55, 0.44-0.70; p < 0.0001) allograft survival at 3 years posttransplant, and with lower mortality. CONCLUSIONS Despite metformin being contraindicated in renal dysfunction, many kidney transplant recipients receive it, and it is not associated with worse patient or allograft survival.
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Affiliation(s)
- Jenise Stephen
- Department of Pharmacy, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minn., USA
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27
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Fantus IG. Is metformin ready for prime time in pregnancy? Probably not yet. Diabetes Metab Res Rev 2015; 31:36-8. [PMID: 25132618 DOI: 10.1002/dmrr.2587] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 07/23/2014] [Indexed: 11/09/2022]
Abstract
Metformin is one of the most commonly used drugs to treat type 2 diabetes and is safe and effective. Its main mechanism of action is thought to be the activation of AMP-activated protein kinase (AMPK) via inhibition of mitochondrial ATP generation. Recent use of metformin as an 'insulin sensitizer' in women with polycystic ovarian syndrome to increase fertility has been successful and resulted in the chance observation that continued use during pregnancy appeared to be safe. There are few studies of metformin in animal models of diabetic pregnancy. However, some data have implicated fetal AMPK activation in neural tube defects. While a recent report suggests that metformin may not activate fetal AMPK, which is reassuring, studies in pregnant woman with gestational diabetes and type 2 diabetes, which are ongoing, require completion before we can conclude that its use in pregnancy is safe. Furthermore, follow-up of the offspring will be critical to determine whether such treatment decreases or increases the development of obesity and diabetes.
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Affiliation(s)
- I George Fantus
- Departments of Medicine and Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Research Institute, University Health Network, Toronto, ON, Canada; Division of Endocrinology and Metabolism Leadership Centre for Diabetes, Mount Sinai Hospital, Toronto, ON, Canada
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28
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Chang W, Chen L, Hatch GM. Berberine as a therapy for type 2 diabetes and its complications: From mechanism of action to clinical studies. Biochem Cell Biol 2014; 93:479-86. [PMID: 25607236 DOI: 10.1139/bcb-2014-0107] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The incidence of type 2 diabetes is increasing rapidly worldwide, and the development of novel anti-diabetic drugs is emerging. However, most anti-diabetic drugs cannot be used in patients with hepatic dysfunction, renal disease, and heart disease, which makes pharmacological therapy of type 2 diabetes complicated. Despite continued introduction of novel agents, the search for an ideal drug that is useful as both a hypoglycemic agent and to reduce diabetes-related complications remains elusive. Berberine is an isoquinoline alkaloid extract that has shown promise as a hypoglycemic agent in the management of diabetes in animal and human studies. Mechanistic studies have revealed beneficial effects of berberine on diabetes-related complications. Although there have been few clinical reports of the anti-diabetic effects of berberine, little documentation of adverse effects in humans positions it as a potential candidate drug to treat type 2 diabetes. In the present review, the anti-diabetic mechanism of berberine, its effect on diabetes-related complications, and its recent use in human clinical studies is highlighted. In addition, we summarize the different treatments for type 2 diabetes in adults and children.
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Affiliation(s)
- Wenguang Chang
- a Department of Pharmacology & Therapeutics, Faculty of Health Sciences, University of Manitoba, Manitoba Institute of Child Health, 501C John Buhler Research Center, 715 McDermot Avenue, Winnipeg, MB, R3E 0P4, Canada
| | - Li Chen
- b Department of Pharmacology, Norman Bethune Medical College, Jilin University, Changchun 130021, China
| | - Grant M Hatch
- a Department of Pharmacology & Therapeutics, Faculty of Health Sciences, University of Manitoba, Manitoba Institute of Child Health, 501C John Buhler Research Center, 715 McDermot Avenue, Winnipeg, MB, R3E 0P4, Canada.,c Department of Biochemistry and Medical Genetics, Faculty of Health Sciences, University of Manitoba, DREAM Theme, Manitoba Institute of Child Health, Winnipeg, MB R3E 0T6, Canada
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29
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Venos ES, Sigal RJ. My patient's diabetic kidney disease has progressed to stage 4; should I discontinue metformin? Can J Diabetes 2014; 38:296-9. [PMID: 25284696 DOI: 10.1016/j.jcjd.2014.07.225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 07/30/2014] [Accepted: 07/31/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Erik S Venos
- Division of Endocrinology, Departments of Medicine and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Ronald J Sigal
- Division of Endocrinology, Departments of Medicine and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiac Sciences and Institute of Public Health, Faculties of Medicine and Kinesiology, University of Calgary, Calgary, Alberta, Canada
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30
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Morgan CL, Mukherjee J, Jenkins-Jones S, Holden SE, Currie CJ. Association between first-line monotherapy with sulphonylurea versus metformin and risk of all-cause mortality and cardiovascular events: a retrospective, observational study. Diabetes Obes Metab 2014; 16:957-62. [PMID: 24720708 DOI: 10.1111/dom.12302] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 03/10/2014] [Accepted: 04/04/2014] [Indexed: 12/11/2022]
Abstract
AIMS To evaluate the risk of all-cause mortality and major adverse cardiovascular events (MACE) for patients exposed to first-line monotherapy with sulphonylurea or metformin. METHODS Data were from the Clinical Practice Research Datalink (CPRD). Patients with type 2 diabetes were selected if initiated with metformin or sulphonylurea monotherapy as their first-line glucose-lowering regimen 2000-2012. The primary endpoint was all-cause mortality; the secondary endpoint was MACE (myocardial infarction or stroke). Times to endpoints were compared using Cox proportional hazards models. Additional analyses were performed on subsets matched directly on key characteristics and by propensity score. RESULTS In the main analysis, 76 811 patients were prescribed metformin monotherapy (mean follow-up 2.9 years) and 15 687 sulphonylurea monotherapy (mean follow-up 3.1 years). A total of 2604 patients were included in each arm of the directly matched cohorts and 8836 in the propensity-matched. With respect to all-cause mortality, using all three analytical approaches the hazard ratio (HR) was significantly increased for sulphonylurea compared with metformin: adjusted HR = 1.580 (95% CI 1.483-1.684) for the main analysis, 1.902 (1.733-2.088) for those matched on propensity score, and 1.272 (1.021-1.584) for the directly matched cohort analysis. For MACE, the respective HRs were 1.196 (1.090-1.313), 1.202 (1.001-1.442) and 0.814 (0.578-1.148), respectively. CONCLUSIONS All-cause mortality was significantly increased in patients prescribed sulphonylurea compared with metformin monotherapy. Whilst residual confounding and confounding by indication may remain, this study indicates that first-line treatment with sulphonylurea monotherapy should be reconsidered.
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Affiliation(s)
- C Ll Morgan
- Global Epidemiology, Pharmatelligence, Cardiff, UK
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31
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Adam WR, O'Brien RC. A justification for less restrictive guidelines on the use of metformin in stable chronic renal failure. Diabet Med 2014; 31:1032-8. [PMID: 24909998 DOI: 10.1111/dme.12515] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 06/03/2014] [Indexed: 11/30/2022]
Abstract
AIM The aim was to justify less restrictive use of metformin in stable chronic renal failure, because a literature review reveals metformin is associated with a significantly lower incidence of cardiovascular events and mortality compared with other hypoglycaemic agents, and metformin-associated lactic acidosis is rare and causation uncertain. Studies on intentional metformin overdose and metformin bioavailability, renal clearance and plasma metformin in renal impairment provide evidence in support of a less restrictive use of metformin. METHODS In metformin overdose (n = 22), lactic acidosis was not inevitable with a plasma metformin > 40 mg/l (therapeutic level c. 1 mg/l): Severe lactic acidosis (pH ≤ 7.21, plasma lactate ≥ 11 mmol/l, n = 8) did not occur unless plasma metformin was > 40 mg/l. Plasma lactate was a more consistent predictor of pH than plasma metformin, with plasma lactate ≤ 4.7 being associated with a pH ≥ 7.34. A likely 'safe' plasma lactate is < 3.5 mmol/l and plasma metformin < 10 mg/l. RESULTS Plasma metformin can be predicted from estimated glomerular filtration rate and metformin dose. Reported plasma metformin in renal failure was always less than predicted plasma metformin. Predicted plasma metformin (mg/l), with an estimated glomerular filtration rate of 30 ml/min and metformin 2000 mg/day was 6.8; an estimated glomerular filtration rate of 20 ml/min and metformin 1500 mg/day was 5.1; an estimated glomerular filtration rate of 10 ml/min and metformin 500 mg/day was 4.4. CONCLUSION Metformin accumulates in renal failure and, although accumulation does not always lead to lactic acidosis, dose modification to achieve a predicted plasma metformin < 10 mg/l is suggested. As plasma metformin is not routinely available, plasma lactate should be useful in monitoring the use of metformin in renal failure.
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Affiliation(s)
- W R Adam
- Rural Health Academic Centre, Shepparton
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32
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Naunton M, Kyle G, Owoka F, Naunton-Boom K. Pharmacist review prevents evolving metformin-associated lactic acidosis. J Clin Pharm Ther 2014; 39:567-70. [DOI: 10.1111/jcpt.12187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 06/02/2014] [Indexed: 01/05/2023]
Affiliation(s)
- M. Naunton
- Faculty of Health; Discipline of Pharmacy; University of Canberra; Bruce ACT Australia
| | - G. Kyle
- Faculty of Health; Discipline of Pharmacy; University of Canberra; Bruce ACT Australia
| | - F. Owoka
- Faculty of Health; Discipline of Pharmacy; University of Canberra; Bruce ACT Australia
| | - K. Naunton-Boom
- Faculty of Health; Discipline of Pharmacy; University of Canberra; Bruce ACT Australia
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Penfornis A, Blicklé JF, Fiquet B, Quéré S, Dejager S. How are patients with type 2 diabetes and renal disease monitored and managed? Insights from the observational OREDIA study. Vasc Health Risk Manag 2014; 10:341-52. [PMID: 24966684 PMCID: PMC4063863 DOI: 10.2147/vhrm.s60312] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and aim Chronic kidney disease (CKD) is frequent in type 2 diabetes mellitus (T2DM), and therapeutic management of diabetes is more challenging in patients with renal impairment (RI). The place of metformin is of particular interest since most scientific societies now recommend using half the dosage in moderate RI and abstaining from use in severe RI, while the classic contraindication with RI has not been removed from the label. This study aimed to assess the therapeutic management, in particular the use of metformin, of T2DM patients with CKD in real life. Methods This was a French cross-sectional observational study: 3,704 patients with T2DM diagnosed for over 1 year and pharmacologically treated were recruited in two cohorts (two-thirds were considered to have renal disease [CKD patients] and one-third were not [non-CKD patients]) by 968 physicians (81% general practitioners) in 2012. Results CKD versus non-CKD patients were significantly older with longer diabetes history, more diabetic complications, and less strict glycemic control (mean glycated hemoglobin [HbA1c] 7.5% versus 7.1%; 25% of CKD patients had HbA1c ≥8% versus 15% of non-CKD patients). Fifteen percent of CKD patients had severe RI, and 66% moderate RI. Therapeutic management of T2DM was clearly distinct in CKD, with less use of metformin (62% versus 86%) but at similar mean daily doses (~2 g/d). Of patients with severe RI, 33% were still treated with metformin, at similar doses. For other oral anti-diabetics, a distinct pattern of use was seen across renal function (RF): use of sulfonylureas (32%, 31%, and 20% in normal RF, moderate RI, and severe RI, respectively) and DPP4-i (dipeptidyl peptidase-4 inhibitors) (41%, 36%, and 25%, respectively) decreased with RF, while that of glinides increased (8%, 14%, and 18%, respectively). CKD patients were more frequently treated with insulin (40% versus 16% of non-CKD patients), and use of insulin increased with deterioration of RF (19%, 39%, and 61% of patients with normal RF, moderate RI, and severe RI, respectively). Treatment was modified at the end of the study-visit in 34% of CKD patients, primarily to stop or reduce metformin. However, metformin was stopped in only 40% of the severe RI patients. Conclusion Despite a fairly good detection of CKD in patients with T2DM, RI was insufficiently taken into account for adjusting anti-diabetic treatment.
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Affiliation(s)
- Alfred Penfornis
- Department of Endocrinology-Metabolism and Diabetology-Nutrition, Jean Minjoz Hospital, University of Franche-Comté, Besançon, France
| | - Jean Frédéric Blicklé
- Department of Internal Medicine and Diabetology, Strasbourg University Hospital, Strasbourg, France
| | - Béatrice Fiquet
- Clinical Affairs, Novartis Pharma SAS, Rueil-Malmaison, France
| | - Stéphane Quéré
- BioStatistics, Novartis Pharma SAS, Rueil-Malmaison, France
| | - Sylvie Dejager
- Clinical Affairs, Novartis Pharma SAS, Rueil-Malmaison, France
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Lalau JD, Arnouts P, Sharif A, De Broe ME. Metformin and other antidiabetic agents in renal failure patients. Kidney Int 2014; 87:308-22. [PMID: 24599253 DOI: 10.1038/ki.2014.19] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/21/2013] [Accepted: 12/12/2013] [Indexed: 12/11/2022]
Abstract
This review mainly focuses on metformin, and considers oral antidiabetic therapy in kidney transplant patients and the potential benefits and risks of antidiabetic agents other than metformin in patients with chronic kidney disease (CKD). In view of the debate concerning lactic acidosis associated with metformin, this review tries to solve a paradox: metformin should be prescribed more widely because of its beneficial effects, but also less widely because of the increasing prevalence of contraindications to metformin, such as reduced renal function. Lactic acidosis appears either as part of a number of clinical syndromes (i.e., unrelated to metformin), induced by metformin (involving an analysis of the drug's pharmacokinetics and mechanisms of action), or associated with metformin (a more complex situation, as lactic acidosis in a metformin-treated patient is not necessarily accompanied by metformin accumulation, nor does metformin accumulation necessarily lead to lactic acidosis). A critical analysis of guidelines and literature data on metformin therapy in patients with CKD is presented. Following the present focus on metformin, new paradoxical issues can be drawn up, in particular: (i) metformin is rarely the sole cause of lactic acidosis; (ii) lactic acidosis in patients receiving metformin therapy is erroneously still considered a single medical entity, as several different scenarios can be defined, with contrasting prognoses. The prognosis for severe lactic acidosis seems even better in metformin-treated patients than in non-metformin users.
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Affiliation(s)
- Jean-Daniel Lalau
- 1] Service d'Endocrinologie et de Nutrition, Centre Hospitalier Universitaire, Amiens, France [2] Unité INSERM U-1088, Université de Picardie Jules Verne, Amiens, France
| | - Paul Arnouts
- Department of Nephrology-Diabetology-Endocrinology, AZ Turnhout, Turnhout, Belgium
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Renal Institute of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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Abstract
Metformin has been the mainstay of therapy for diabetes mellitus for many years; however, the mechanistic aspects of metformin action remained ill-defined. Recent advances revealed that this drug, in addition to its glucose-lowering action, might be promising for specifically targeting metabolic differences between normal and abnormal metabolic signalling. The knowledge gained from dissecting the principal mechanisms by which metformin works can help us to develop novel treatments. The centre of metformin's mechanism of action is the alteration of the energy metabolism of the cell. Metformin exerts its prevailing, glucose-lowering effect by inhibiting hepatic gluconeogenesis and opposing the action of glucagon. The inhibition of mitochondrial complex I results in defective cAMP and protein kinase A signalling in response to glucagon. Stimulation of 5'-AMP-activated protein kinase, although dispensable for the glucose-lowering effect of metformin, confers insulin sensitivity, mainly by modulating lipid metabolism. Metformin might influence tumourigenesis, both indirectly, through the systemic reduction of insulin levels, and directly, via the induction of energetic stress; however, these effects require further investigation. Here, we discuss the updated understanding of the antigluconeogenic action of metformin in the liver and the implications of the discoveries of metformin targets for the treatment of diabetes mellitus and cancer.
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Affiliation(s)
- Ida Pernicova
- Department of Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London EC1A 6BQ, UK
| | - Márta Korbonits
- Department of Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Charterhouse Square, London EC1A 6BQ, UK
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36
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Kajbaf F, Mentaverri R, Diouf M, Fournier A, Kamel S, Lalau JD. The Association between 25-Hydroxyvitamin D and Hemoglobin A1c Levels in Patients with Type 2 Diabetes and Stage 1-5 Chronic Kidney Disease. Int J Endocrinol 2014; 2014:142468. [PMID: 25250050 PMCID: PMC4163314 DOI: 10.1155/2014/142468] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/18/2014] [Accepted: 08/14/2014] [Indexed: 12/03/2022] Open
Abstract
Aim. To examine the relationship between plasma 25-hydroxyvitamin D (25(OH)D) levels and blood hemoglobin A1c (HbA1c) levels in diabetic patients at various stages of chronic kidney disease (CKD). Methods. We screened for data collected between 2003 and 2012. The correlation between 25(OH)D and HbA1c levels was studied in patients categorized according to the severity of CKD and their vitamin D status. A multivariate linear regression model was used to determine whether 25(OH)D and HbA1c levels were independently associated after adjustment for a number of covariates (including erythrocyte metformin levels). Results. We identified 542 reports from 245 patients. The mean HbA1c value was 6.7 ± 1.0% in vitamin D sufficiency, 7.3 ± 1.5% in insufficiency, and 8.4 ± 2.0% in deficiency (P < 0.0001). There was a negative correlation between 25(OH)D and HbA1c levels for the population as a whole (r = -0.387, P < 0.0001) and in the CKD severity subgroups (r = -0.384, P < 0.0001 and r = -0.333, P < 0.0001 for CKD stages 1-3 and 4-5, resp.). In the multivariate analysis, the 25(OH)D level was the only factor associated with HbA1c (P < 0.0001). Conclusion. 25(OH)D levels were negatively correlated with HbA1c levels independently of study covariates.
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Affiliation(s)
- Farshad Kajbaf
- Department of Endocrinology and Nutrition, University Hospital of Amiens, 80054 Amiens, France
- INSERM Unit 1088, Jules Verne University of Picardie, 80037 Amiens, France
| | - Romuald Mentaverri
- INSERM Unit 1088, Jules Verne University of Picardie, 80037 Amiens, France
- Bone Biology and Endocrine Division, University Hospital of Amiens, 80054 Amiens, France
| | - Momar Diouf
- Clinical Research Center, University Hospital of Amiens, 80054 Amiens, France
| | - Albert Fournier
- Department of Clinical Nephrology, University Hospital of Amiens, 80054 Amiens, France
| | - Said Kamel
- Bone Biology and Endocrine Division, University Hospital of Amiens, 80054 Amiens, France
| | - Jean-Daniel Lalau
- Department of Endocrinology and Nutrition, University Hospital of Amiens, 80054 Amiens, France
- INSERM Unit 1088, Jules Verne University of Picardie, 80037 Amiens, France
- *Jean-Daniel Lalau:
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