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Fan Y, Cai Q, Chen S, Zhang B, Zhang Y, Zhen J, Zhang G. Appraisal of guidelines for managing contrast medium in patients with metformin: consensuses, controversies, and gaps. Eur Radiol 2023; 33:6290-6298. [PMID: 37133520 DOI: 10.1007/s00330-023-09611-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 02/11/2023] [Accepted: 02/17/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVES The current guidelines contain substantial inconsistency regarding the use of metformin concomitantly with contrast media. The objective of this study is to appraise the guidelines and summarize the agreements and differences among recommendations. METHODS Our search focused on English language guidelines published between 2018 and 2021. Guidelines for the management of contrast media in patients with continuous metformin were included. Guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. RESULTS Six guidelines out of 1134 fulfilled the inclusion criteria with an AGREE II score of 79.2% (IQR 72.7 to 85.1%). There was good overall quality of the guidelines, with six considered "strongly recommended." CPGs scored poorly in "Clarity of Presentation" and "Applicability," with scores of 75.9% and 76.4%, respectively. The intraclass correlation coefficients were excellent in each domain. There are some guidelines (33.3%) that recommend discontinuation of metformin in patients with an eGFR of < 30 mL/min/1.73 m2, while some guidelines (16.7%) suggest the threshold of renal function should be eGFR < 40 mL/min/1.73 m2. CONCLUSIONS Most guidelines recommend withdrawing metformin before using contrast agents in diabetic patients with severely impaired kidney function but disagree on the renal function thresholds. Furthermore, the gaps regarding discontinuing metformin with moderate renal impairment (30 mL/min/1.73 m2 < eGFR < 60 mL/min/1.73 m2) must be considered in future studies. KEY POINTS • Guidelines involving metformin and contrast agents are reliable and optimal. • Most guidelines advocate discontinuing metformin before using contrast agents in diabetic patients with advanced renal failure, but there are controversial suggestions regarding kidney function thresholds. • The gaps regarding the time of discontinuation of the metformin with moderate renal impairment (30 mL/min/1.73 m2 < eGFR < 60 mL/min/1.73 m2) must be considered in the extensive RCT studies.
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Affiliation(s)
- Yongqiang Fan
- Department of Cardiology, DongGuan Tungwah Hospital, DongGuan, China
- Department of Cardiology, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qingqing Cai
- Department of Cardiology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23, Beijie Road, Jiangmen, 529000, Guangdong, China
- Department of Cardiology, GuangDong Medical University, Zhanjiang, China
| | - Shunhua Chen
- Department of Cardiology, DongGuan Tungwah Hospital, DongGuan, China
| | - Bin Zhang
- Department of Cardiology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23, Beijie Road, Jiangmen, 529000, Guangdong, China
| | - Yixun Zhang
- Department of Cardiology, DongGuan Tungwah Hospital, DongGuan, China
| | - Jinhuan Zhen
- Department of Cardiology, KaiPing Second People's Hospital, No. 22, Shixi Road, Jiangmen, 529300, Guangdong, China.
| | - Gaoxing Zhang
- Department of Cardiology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23, Beijie Road, Jiangmen, 529000, Guangdong, China.
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Kao TW, Lee KH, Chan WP, Fan KC, Liu CW, Huang YC. Continuous use of metformin in patients receiving contrast medium: what is the evidence? A systematic review and meta-analysis. Eur Radiol 2022; 32:3045-3055. [PMID: 34837099 DOI: 10.1007/s00330-021-08395-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Substantial inconsistencies exist in current guidelines regarding recommendations of metformin usage with the administration of a contrast medium. We aimed to perform a meta-analysis to determine whether the risks of contrast-induced acute kidney injury (CI-AKI) and lactic acidosis increase with metformin use in diabetic patients receiving a contrast medium. METHODS Studies were retrieved from databases from inception to May 15, 2021. Studies that compared the outcomes of using metformin with not using metformin during contrast medium administration were included. The primary outcomes were incidence of CI-AKI and lactic acidosis. The secondary outcomes were renal function changes from baseline. Data analysis was using risk ratio (RR) for dichotomous outcomes and mean differences (MD) with 95% confidence intervals (CI) for continuous outcomes. RESULTS Analyses of two randomized controlled trials and four retrospective cohorts examining a total of 1459 patients revealed no significant differences in the incidence of CI-AKI (RR = 1.08; 95% CI, 0.72 to 1.63) and in changes in renal function measurements (serum creatinine: MD = 0.00 mg/dL, 95% CI, - 0.05 to 0.05; estimated glomerular filtration rate: MD = 0.22, 95% CI, - 2.47 to 2.91) after contrast medium administration between patients using and not using metformin. CONCLUSIONS There is no evidence that continuing metformin during contrast medium administration is associated with a higher risk of CI-AKI, lactic acidosis, or renal function deterioration compared to patients who discontinued metformin or who were not metformin users. The limited quality of the included studies may compromise the strength of evidence provided in this meta-analysis. KEY POINTS There is no need to discontinue metformin either before or after intravenous contrast medium exposure in patients with eGFR > 30 mL/min/1.73 m2. In patients receiving intra-arterial contrast medium with first-pass renal exposure, there is no need to withhold metformin if eGFR is above 60 mL/min/1.73 m2. For patients who have an eGFR level between 30 and 60 mL/min/1.73 m2 and are receiving intra-arterial contrast medium with first-pass renal exposure, no case of lactic acidosis was observed based on present data, but further evidence is needed to make a strong suggestion regarding its safety.
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Affiliation(s)
- Ting-Wan Kao
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Hua Lee
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wing P Chan
- Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Kang-Chih Fan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Che-Wei Liu
- Department of Orthopedics, Cathay General Hospital, Taipei, Taiwan
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chen Huang
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
- Department of Dermatology, Wan Fang Hospital, Taipei Medical University, No. 111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei City, Taiwan.
- Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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