Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease

Abstract

Background Recent changes to the Food and Drug Administration boxed warning for metformin will increase use in individuals with historical contraindications or precautions. Prescribers must understand clinical outcomes of metformin use in these populations. Purpose To synthesize data addressing outcomes of metformin use in populations with type 2 diabetes and moderate-to-severe chronic kidney disease, congestive heart failure, or chronic liver disease with hepatic impairment. Data Sources MEDLINE (via PubMed) from January 1994 to September 2016; Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015. Study Selection English-language studies that examined adults with type 2 diabetes and chronic kidney disease with eGFR <60 mL/min/1.73m2, congestive heart failure, or chronic liver disease with hepatic impairment; compared diabetes regimens that included metformin to regimens that did not; and reported all-cause mortality, major adverse cardiovascular events and other outcomes of interest. Data Extraction Two reviewers abstracted data and independently rated study quality and strength of evidence. Data Synthesis Based on quantitative/qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with chronic kidney disease, congestive heart failure, and chronic liver disease with hepatic impairment, and reduced heart failure readmission in patients with chronic kidney disease and congestive heart failure. Limitations We identified low strength of evidence and sparse data on multiple outcomes of interest. Available studies were observational and had varying follow-up durations. Conclusions Metformin use in patients with moderate chronic kidney disease, congestive heart failure, or chronic liver disease with hepatic impairment is associated with improvements in key clinical outcomes. Our findings support recent changes in metformin labeling. Registration PROSPERO CRD42016027708 Funding Source U.S. Department of Veterans Affairs

Multidimensional effects of metformin in patients with type 2 diabetes

“…Диагностика, контроль, лечение Diagnosis, control, treatment в июле 2016 г. вслед за соответствующим решением FDA [31]. Так, в противопоказаниях отражена ХСН с не-стабильными показателями гемодинамики без указания степени по NYHA; в разделе «с осторожностью» уточнены использование метформина у лиц старше 60 лет, выпол-няющих тяжелую физическую работу (в связи с риском лактацидоза), и клиренс креатинина менее 45 мл/мин (ранее было противопоказанием).…”

Pharmacological management of type 2 diabetes: what’s new in 2017?

“…Of major interest, recent observational data have suggested that T2D patients considered at risk because of the presence of traditional contraindications may still derive benefit from metformin therapy with reductions in morbidity and mortality compared with other glucose-lowering agents, especially sulfonylureas (though a properly-designed head to head CV outcome trial is lacking), and without increased risk of lactic acidosis. [11,12]. This concerns patients with CV disease, including stable heart failure (HF), [11,12], but also T2D patients with mild to moderate CKD.…”

“…[11,12]. This concerns patients with CV disease, including stable heart failure (HF), [11,12], but also T2D patients with mild to moderate CKD. [13] These observations led the US Food and Drug Administration (FDA ; April 8, 2016) and the European Medications Agency (EMA ; October 13, 2016) to allow the prescription of metformin in patients with an estimated glomerular filtration rate (eGFR) between 30 and 59 ml/min/1.73 m², provided that some rules of good practice are respected.…”

“…[2] These recent changes will increase the use of metformin in T2D patients with historical contraindications or precautions, especially in the elderly. [12] …”

Metformina en enfermedad renal diabética: estado actual

“…• Crowley y colaboradores 34 , en una revisión sistemática de varios estudios que utilizaron metformina en pacientes con contraindicaciones históricas (ERD con TFG menor de 60 mL/ min/1,73 m 2 , insuficiencia cardíaca o enfermedad hepática), encontraron que su empleo estuvo asociado con reducción en la mortalidad total y con menos readmisiones por insuficiencia cardíaca, en los pacientes con ERC o falla cardíaca.…”