Safe Use of Metformin in Adults With Type 2 Diabetes and Chronic Kidney Disease: Lower Dosages and Sick-Day Education Are Essential

Chronic Kidney Disease of Unknown Etiology: A Global Health Threat in Rural Agricultural Communities-Prevalence, Suspected Causes, Mechanisms, and Prevention Strategies

Chronic Kidney Disease of Unknown Etiology (CKDu) is a worldwide hidden health threat that is associated with progressive loss of kidney functions without showing any initial symptoms until reaching end-stage renal failure, eventually leading to death. It is a growing health problem in Asia, Central America, Africa, and the Middle East, with identified hotspots. CKDu disease mainly affects young men in rural farming communities, while its etiology is not related to hypertension, kidney stones, diabetes, or other known causes. The main suspected causal factors are heat-stress, dehydration, exposure to agrochemicals, heavy metals and use of hard water, infections, mycotoxins, nephrotoxic agents, altitude, and genetic factors. This review gives an overview of CKDu and sheds light on its medical history, geographic distribution, and worldwide prevalence. It also summarizes the suspected causal factors, their proposed mechanisms of action, as well as the main methods used in the CKDu prior detection and surveillance. In addition, mitigation measures to reduce the burden of CKDu are also discussed. Further investigation utilizing more robust study designs would provide a better understanding of the risk factors linked to CKDu and their comparison between affected regions.

Optimizing metformin therapy in practice: Tailoring therapy in specific patient groups to improve tolerability, efficacy and outcomes

Metformin is the first-line medication for type 2 diabetes. It is effective and safe, provided some caution is taken in specific populations. In patients with chronic kidney disease, metformin may provide long-term benefits, and it is a first-line therapy for diabetes, but the estimated glomerular filtration rate (eGFR) must be assessed regularly, to minimize the risk for metformin accumulation. When eGFR is 30-60 mL/min/1.73m2, the dose should be reconsidered, and sick-days education provided. Metformin should be discontinued when eGFR falls below 30 mL/min/1.73m2. Metformin accumulation may increase the risk for lactic acidosis if concomitant risk factors for hyperlactataemia (liver or respiratory insufficiency, sepsis, acute heart failure) are present; in these conditions, metformin is contraindicated, even although the available evidence is reassuring. Patients on metformin often complain of gastrointestinal side effects (mainly diarrhoea and nausea) during therapy initiation, but they may sometimes occur after years of stable therapy. These usually resolve if the dose is carefully titrated, or by switching to the extended-release formulation. Patients with obesity may benefit from the significant, although modest, metformin-associated weight loss and appetite reduction. During pregnancy, metformin is associated with a reduction of pregnancy complications, especially in obese women, but some concern remains, because metformin crosses the placenta, and it is associated with a significantly lower mean birth weight than insulin. In the elderly, gastrointestinal tolerability and renal function must be reassessed more often. Vitamin B-12 should be screened regularly in long-time metformin users because metformin may induce clinical vitamin B-12 deficiency.

Pharmacotherapy of type 2 diabetes: An update and future directions

Type 2 diabetes (T2D) is a widely prevalent disease with substantial economic and social impact for which multiple conventional and novel pharmacotherapies are currently available; however, the landscape of T2D treatment is constantly changing as new therapies emerge and the understanding of currently available agents deepens. This review aims to provide an updated summary of the pharmacotherapeutic approach to T2D. Each class of agents is presented by mechanism of action, details of administration, side effect profile, cost, and use in certain populations including heart failure, non-alcoholic fatty liver disease, obesity, chronic kidney disease, and older individuals. We also review targets of novel therapeutic T2D agent development. Finally, we outline an up-to-date treatment approach that starts with identification of an individualized goal for glycemic control then selection, initiation, and further intensification of a personalized therapeutic plan for T2D.

Does the Same Hyperlactatemia Cut-Off in the Context of Acute Diseases Hold the Same Meaning in Diabetes Mellitus?

Background

Hyperlactatemia is defined by a lactate concentration of >2 mmol/L, and a lactate concentration of above >4 mmol/L is commonly used to define severe hyperlactatemia. It is a common disorder in critically ill patients and is associated with adverse prognosis. Diabetes mellitus(DM) can also be associated with increased lactate levels at baseline. In this study, we aimed to document the development of severe hyperlactatemia in acute situations among patients with and without DM, to analyze potential contributors to lactate elevation and their impact on mortality, and to analyze whether lactate concentrations of >4 mmol/L have equal prognostic significance in patients with and without DM.

Methodology

A retrospective, cross-sectional study was performed among patients admitted to our internal medicine wards in the context of acute disease with lactate concentrations of ​​≥2 mmol/L. Data were collected regarding age, sex, highest lactate concentrations, cause of hyperlactatemia, DM, and mortality. Statistical analysis was performed using SPSS version 23.

Results

In total, 151 patients with lactate levels of ≥2 mmol/L were analyzed. The mean age of the patients was 78.2 ± 14.9 years, and 55% of the patients were female. Overall, 55.6% of the patients had DM, as well as higher lactatemia of 6.3 ± 3.4 mmol/L (vs 5.1 ± 3.2 in non-DM patients, p = 0.003), with the majority reaching values of >4 mmol/L (vs 34.8% in non-DM patients). When potential contributors to the development of severe hyperlactatemia (lactate >4 mmol/L) were analyzed in DM patients, metformin consumption concomitantly with factors potentiating its accumulation, sepsis/septic shock, ischemia, and neoplasia were the most frequently identified contributors. In non-DM patients, the three former factors were also the most frequently reported. The 30-day mortality rate was 25.82%, with deceased patients also displaying a higher lactatemia of 6.5 ± 3.2 mmol/L (vs. 5.5 ± 3.3 mmol/L in patients who survived) (p = 0.037). In multivariate analysis, lactate values of >4 mmol/L were an independent predictor of mortality in the entire sample and in the subgroup without DM, but not in DM patients.

Conclusions

In our sample, patients with DM had higher lactate levels than non-DM patients. Our analysis raises the possibility that the same lactate values may not have equal capacity to assess prognosis in acute situations in patients with and without DM. Large-scale studies are needed to optimize cut-off points for lactatemia in patients with high baseline values, such as DM patients.

A survey on consciousness towards the proper use of metformin and medical cost in Japanese patients with type 2 diabetes

To investigate the patients' consciousness regarding the use of metformin and medical cost in Japanese patients with type 2 diabetes taking metformin. This cross-sectional study investigated patients' general characteristics and consciousness regarding medical cost, kidney function, liver function, and metformin usage, using a self-administered, internet-based questionnaire. Among 1,000 patients, 81.0% felt unsatisfied with treatment for type 2 diabetes, with the main reason for dissatisfaction being high medical cost, with 540 patients reporting this. In addition, 16.8% of patients experienced treatment disruption and among them, 48.2% (81/168) answered that the reason was high medical cost. Over half of the patients did not understand their kidney and liver functions, respectively. Only 8.9% and 7.1% of patients knew both the words and meanings behind sick days and lactic acidosis, respectively. In conclusion, many patients with type 2 diabetes taking metformin were not satisfied with their treatments, with the main reason being high medical cost. Moreover, they did not have sufficient knowledge of sick days and/or lactic acidosis.

Pharmaceutical Drugs and Natural Therapeutic Products for the Treatment of Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is the most widespread form of diabetes, characterized by chronic hyperglycaemia, insulin resistance, and inefficient insulin secretion and action. Primary care in T2DM is pharmacological, using drugs of several groups that include insulin sensitisers (e.g., biguanides, thiazolidinediones), insulin secretagogues (e.g., sulphonylureas, meglinides), alpha-glucosidase inhibitors, and the newest incretin-based therapies and sodium-glucose co-transporter 2 inhibitors. However, their long-term application can cause many harmful side effects, emphasising the importance of the using natural therapeutic products. Natural health substances including non-flavonoid polyphenols (e.g., resveratrol, curcumin, tannins, and lignans), flavonoids (e.g., anthocyanins, epigallocatechin gallate, quercetin, naringin, rutin, and kaempferol), plant fruits, vegetables and other products (e.g., garlic, green tea, blackcurrant, rowanberry, bilberry, strawberry, cornelian cherry, olive oil, sesame oil, and carrot) may be a safer alternative to primary pharmacological therapy. They are recommended as food supplements to prevent and/or ameliorate T2DM-related complications. In the advanced stage of T2DM, the combination therapy of synthetic agents and natural compounds with synergistic interactions makes the treatment more efficient. In this review, both pharmaceutical drugs and selected natural products, as well as combination therapies, are characterized. Mechanisms of their action and possible negative side effects are also provided.

Metformin Benefits: Another Example for Alternative Energy Substrate Mechanism?

Since the UK Prospective Diabetes Study (UKPDS), metformin has been considered the first-line medication for patients with newly diagnosed type 2 diabetes. Though direct evidence from specific trials is still lacking, several studies have suggested that metformin may protect from diabetes- and nondiabetes-related comorbidities, including cardiovascular, renal, neurological, and neoplastic diseases. In the past few decades, several mechanisms of action have been proposed to explain metformin's protective effects, none being final. It is certain, however, that metformin increases lactate production, concentration, and, possibly, oxidation. Once considered a mere waste product of exercising skeletal muscle or anaerobiosis, lactate is now known to act as a major energy shuttle, redistributed from production sites to where it is needed. Through the direct uptake and oxidation of lactate produced elsewhere, all end organs can be rapidly supplied with fundamental energy, skipping glycolysis and its possible byproducts. Increased lactate production (and consequent oxidation) could therefore be considered a positive mechanism of action of metformin, except when, under specific circumstances, metformin and lactate become excessive, increasing the risk of lactic acidosis. We are proposing that, rather than considering metformin-induced lactate production as dangerous, it could be considered a mechanism through which metformin exerts its possible protective effect on the heart, kidneys, and brain and, to some extent, its antineoplastic action.

Metformin use in patients with type 2 diabetes mellitus and chronic kidney disease: An evidence-based review

INTRODUCTION

Practice guidelines advise caution on the use of metformin in patients with type 2 diabetes mellitus with chronic kidney disease (CKD). This review aims to examine the evidence for the benefits and risks of metformin use in patients with T2DM and CKD.

METHODS

The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and PubMed were searched; the references of selected papers were hand searched. Systematic reviews, randomised controlled trials, cohort studies, case series and case-control studies were included. The full text of selected articles was reviewed. The outcomes studied were all-cause mortality, cardiovascular complications, lactic acidosis and worsening of renal function. Recommendations were graded according to the Scottish Intercollegiate Guidelines Network system.

RESULTS

A total of 139 unique articles were identified, 14 of which met the inclusion criteria and were selected for full-text review. Four cohort studies reported an association between metformin use and improved all-cause mortality in CKD stage 4 and better. Two cohort studies reported improved cardiovascular outcomes with metformin use. Four cohort studies, 1 case series and 1 case-control study reported no significant association between metformin use and an increased risk of lactic acidosis in CKD. There is a moderate level of evidence to support reduced mortality, improved cardiovascular outcomes and a low risk of lactic acidosis with metformin use in patients with T2DM and with CKD stage 4 and above.

CONCLUSION

Existing recommendations to restrict metformin use in diabetes patients with CKD need to be reviewed in light of emerging evidence supporting its overall benefits in these patients.

Can the biological mechanisms of ageing be corrected by food supplementation. The concept of health care over sick care

"From care for the sick to care for health" implies that age-related diseases and discomforts, which impair the quality of life, should be prevented rather than treated. Healthy lifestyle and nutrition, and hormone supplementation - when needed - are of crucial importance. Food supplementation with nutraceuticals composed of vitamins, oligo-minerals, plant extracts and essential amino- and fatty acids should reduce age-related oxidative and epigenetic damage to DNA, and inhibit inflammatory and metabolic impairment. This study of the potential beneficial effects of novel nutraceuticals on the biological mechanisms of physical and mental ageing suggests these supplements may be scientifically justified. In the absence of adverse side effects and the expected favourable effect on the quality-adjusted life years, the benefit over risk ratio of nutraceutical supplementation should be positive.

Evidence-based treatment of hyperglycaemia with incretin therapies in patients with type 2 diabetes and advanced chronic kidney disease

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.

Metformin and cardiorenal outcomes in diabetes: A reappraisal

The guidance issued to the pharmaceutical industry by the US Food and Drug Administration in 2008 has led to the publication of a series of randomized, controlled cardiovascular outcomes trials with newer therapeutic classes of glucose-lowering medications. Several of these trials, which evaluated the newer therapeutic classes of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, have reported a reduced incidence of major adverse cardiovascular and/or renal outcomes, usually relative to placebo and standard of care. Metformin was the first glucose-lowering agent reported to improve cardiovascular outcomes in the UK Prospective Diabetes Study (UKPDS) and thus became the foundation of standard care. However, as this clinical trial reported more than 20 years ago, differences from current standards of trial design and evaluation complicate comparison of the cardiovascular profiles of older and newer agents. Our article revisits the evidence for cardiovascular protection with metformin and reviews its effects on the kidney.

A Patient Safety Educational Tool for Patients With Chronic Kidney Disease: Development and Usability Study

Background

Chronic kidney disease (CKD) is a health condition that threatens patient safety; however, few interventions provide patient-centered education about kidney-specific safety hazards.

Objective

We sought to develop and test the usability of a mobile tablet–based educational tool designed to promote patient awareness of relevant safety topics in CKD.

Methods

We used plain language principles to develop content for the educational tool, targeting four patient-actionable safety objectives that are relevant for individuals with CKD. These four objectives included avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs); hypoglycemia awareness (among individuals with diabetes); temporary cessation of certain medications during acute volume depletion to prevent acute kidney injury (ie, “sick day protocol”); and contrast dye risk awareness. Our teaching strategies optimized human-computer interaction and content retention using audio, animation, and clinical vignettes to reinforce themes. For example, using a vignette of a patient with CKD with pain and pictures of common NSAIDs, participants were asked “Which of the following pain medicines are safe for Mr. Smith to take for his belly pain?” Assessment methods consisted of preknowledge and postknowledge surveys, with provision of correct responses and explanations. Usability testing of the tablet-based tool was performed among 12 patients with any stage of CKD, and program tasks were rated upon completion as no error, noncritical error (self-corrected), or critical error (needing assistance).

Results

The 12 participants in this usability study were predominantly 65 years of age or older (n=7, 58%) and female (n=7, 58%); all participants owned a mobile device and used it daily. Among the 725 total tasks that the participants completed, there were 31 noncritical errors (4.3%) and 15 critical errors (2.1%); 1 participant accounted for 30 of the total errors. Of the 12 participants, 10 (83%) easily completed 90% or more of their tasks. Most participants rated the use of the tablet as very easy (n=7, 58%), the activity length as “just right” (rather than too long or too short) (n=10, 83%), and the use of clinical vignettes as helpful (n=10, 83%); all participants stated that they would recommend this activity to others. The median rating of the activity was 8 on a scale of 1 to 10 (where 10 is best). We incorporated all participant recommendations into the final version of the educational tool.

Conclusions

A tablet-based patient safety educational tool is acceptable and usable by individuals with CKD. Future studies leveraging iterations of this educational tool will explore its impact on health outcomes in this high-risk population.

Safety of Metformin in Psoriasis Patients With Diabetes Mellitus: A 17-Year Population-Based Real-World Cohort Study

CONTEXT

The safety of metformin usage by diabetic psoriasis patients is unclear.

OBJECTIVE

To investigate the real-world safety of metformin in psoriatic patients with type 2 diabetes mellitus (T2DM).

DESIGN

We used the National Health Insurance Research Database to perform a cohort study. Based on metformin and other antidiabetic agent prescriptions, we divided all psoriasis patients with T2DM into the metformin group and the nonmetformin group. The outcomes included all-cause mortality, severe psoriasis, hospitalization due to psoriasis, and any cause for readmission.

RESULTS

The metformin group (n = 5520) and the nonmetformin group (n = 3062) did not significantly differ in the risk of all-cause mortality [hazard ratio (HR) 1.08; 95% CI, 0.90 to 1.30], severe psoriasis (HR, 0.95; 95% CI, 0.80 to 1.09), psoriasis-related admission (HR, 1.32; 95% CI, 0.90 to 1.93), and any-cause readmission (HR, 0.99; 95% CI, 0.90 to 1.11). The dose-response analysis found no significant increase in the risk of severe psoriasis and psoriasis-related admission, even with more than 80 defined daily doses or 1000 mg daily dose of metformin prescribed (P for linear trend > 0.05).

CONCLUSION

Metformin can be prescribed for diabetic psoriasis patients without safety concerns.