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Research Progress of Population Pharmacokinetic of Metformin. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4071111. [PMID: 36578804 PMCID: PMC9792241 DOI: 10.1155/2022/4071111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/21/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022]
Abstract
Metformin is commonly used as first-line treatment for T2DM (type2 diabetes mellitus). Owing to the high pharmacokinetic (PK) variability, several population pharmacokinetic (PPK) models have been developed for metformin to explore potential covariates that affect its pharmacokinetic variation. This comprehensive review summarized the published PPK studies of metformin, aimed to summarize PPK models of metformin. Most studies described metformin pharmacokinetics as a 2-compartment (2-CMT) model with 4 study describing its pharmacokinetics as 1-compartment (1-CMT). Studies on metformin PPK have shown that obesity, creatinine clearance (CLCr), gene polymorphism, degree of renal function damage, and pathological conditions all have a certain impact on the PK parameters of metformin. It is particularly important to formulate individualized dosing regimens. For future PPK studies of metformin, we believe that more attention should be paid to special populations.
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Harding SA, Biary R, Hoffman RS, Su MK, Howland MA. A Pharmacokinetic Analysis of Hemodialysis for Metformin-Associated Lactic Acidosis. J Med Toxicol 2020; 17:70-74. [PMID: 32789583 DOI: 10.1007/s13181-020-00802-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Although hemodialysis is recommended for patients with severe metformin-associated lactic acidosis (MALA), the amount of metformin removed by hemodialysis is poorly documented. We analyzed endogenous clearance and hemodialysis clearance in a patient with MALA. METHODS A 62-year-old man with a history of type II diabetes mellitus presented after several days of vomiting and diarrhea and was found to have acute kidney injury (AKI) and severe acidemia. Initial serum metformin concentration was 315.34 μmol/L (40.73 μg/mL) (typical therapeutic concentrations 1-2 μg/mL). He underwent 6 h of hemodialysis. We collected hourly whole blood, serum, urine, and dialysate metformin concentrations. Blood, urine, and dialysate samples were analyzed, and clearances were determined using standard pharmacokinetic calculations. RESULTS The total amount of metformin removed by 6 h of hemodialysis was 888 mg, approximately equivalent to one therapeutic dose. Approximately 142 mg of metformin was cleared in the urine during this time. His acid-base status and creatinine improved over the following days. No further hemodialysis was required. CONCLUSION We report a case of MALA likely secondary to AKI and severe volume depletion. The patient improved with supportive care, sodium bicarbonate, and hemodialysis. Analysis of whole blood, serum, urine, and dialysate concentrations showed limited efficacy of hemodialysis in the removal of metformin from blood, contrary to previously published data. Despite evidence of acute kidney injury, a relatively large amount of metformin was eliminated in the urine while the patient was undergoing hemodialysis. These data suggest that clinical improvement is likely due to factors besides removal of metformin.
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Affiliation(s)
- Stephen A Harding
- Division of Medical Toxicology, Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, 1504 Ben Taub Loop, Houston, TX, 77030, USA.
| | - Rana Biary
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| | - Mary Ann Howland
- New York City Poison Control Center, New York, NY, USA
- St. John's University College of Pharmacy and Health Sciences, New York, NY, USA
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Sinnappah KA, Kuan IHS, Thynne TRJ, Doogue MP, Wright DFB. The pharmacokinetics of metformin in patients receiving intermittent haemodialysis. Br J Clin Pharmacol 2020; 86:1430-1443. [PMID: 32060931 DOI: 10.1111/bcp.14244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 12/23/2022] Open
Abstract
The aims of this study were to characterise the population pharmacokinetics of metformin in patients receiving haemodialysis, and to determine the doses that will maintain median metformin plasma concentrations below 5 mg L-1 for a typical individual. Metformin plasma concentrations from 5 patients receiving thrice weekly intermittent haemodialysis followed by metformin 500 mg postdialysis were fitted to a published pharmacokinetic model. Additional models to describe the dialytic pharmacokinetics of metformin were explored. Doses of 250 and 500 postdialysis were simulated from the model for a typical haemodialysis patient. The published 2-compartment pharmacokinetic model with an additional parameter to describe haemodialysis clearance provided a reasonable fit to the data. Deterministic simulations from the model for a typical individual suggest that metformin doses of 250-500 mg postdialysis and 250 mg given once daily should maintain median metformin plasma concentrations below 5 mg L-1 .
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Affiliation(s)
| | | | - Tilenka R J Thynne
- Department of Clinical Pharmacology, Flinders Medical Centre and Flinders University, Adelaide, Australia
| | - Matthew P Doogue
- Department of Medicine, University of Otago, Christchurch, New Zealand
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Abdel Shaheed C, Carland JE, Graham GG, Stocker SL, Smith G, Hicks M, Williams KM, Furlong T, Macdonald P, Greenfield JR, Smith FC, Chowdhury G, Day RO. Is the use of metformin in patients undergoing dialysis hazardous for life? A systematic review of the safety of metformin in patients undergoing dialysis. Br J Clin Pharmacol 2019; 85:2772-2783. [PMID: 31471973 DOI: 10.1111/bcp.14107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/04/2019] [Accepted: 08/18/2019] [Indexed: 12/22/2022] Open
Abstract
AIMS Metformin may have clinical benefits in dialysis patients; however, its safety in this population is unknown. This systematic review evaluated the safety of metformin in dialysis patients. METHODS MEDLINE, Embase, CENTRAL, PsycINFO and the Cochrane Library were searched for randomised controlled trials and observational studies evaluating metformin use in dialysis patients. Three authors reviewed the studies and extracted data. The primary outcomes were mortality, occurrence of lactic acidosis and myocardial infarction (MI) in patients taking metformin during dialysis treatment for ≥12 months (long term). Risk of bias was assessed using Risk Of Bias In Nonrandomised Studies of Interventions (ROBINS-1). Overall quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Fifteen observational studies were eligible; 7 were prospective observational studies and 8 were case reports/case series. No randomised controlled trials were identified. The 7 prospective observational studies (n = 194) reported on cautious metformin use in patients undergoing maintenance dialysis. Only 3 provided long-term follow-up data. In 2 long-term studies of metformin therapy (≤1000 mg/d) in patients undergoing peritoneal dialysis (PD), 1 reported 6 deaths (6/83; 7%) due to major cardiovascular events (3 MI) and the other reported no deaths (0/35). One long-term study of metformin therapy (250 mg to 500 mg thrice weekly) in patients undergoing haemodialysis reported 4 deaths (4/61; 7%) due to major cardiovascular events (2 MI). These findings provide very low-quality evidence as they come from small observational studies. CONCLUSION The evidence regarding the safety of metformin in people undergoing dialysis is inconclusive. Appropriately designed randomised controlled trials are needed to resolve this uncertainty.
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Affiliation(s)
- Christina Abdel Shaheed
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Greg Smith
- Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Mark Hicks
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kenneth M Williams
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Timothy Furlong
- Department of Nephrology, St Vincent's Hospital, Sydney, Australia
| | - Peter Macdonald
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Jerry R Greenfield
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia.,Diabetes and Metabolism Division, Garvan Institute of Metabolic Research, Sydney, Australia.,Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Gina Chowdhury
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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Stefani M, Roberts DM. Complex decisions in the use of extracorporeal treatments in acute metformin overdose: which modality, when and how to measure the effect. Br J Clin Pharmacol 2018; 84:2689-2691. [PMID: 30194775 PMCID: PMC6255999 DOI: 10.1111/bcp.13762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/23/2018] [Accepted: 09/04/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Maurizio Stefani
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalDarlinghurstNSWAustralia
- St Vincent's Clinical SchoolUniversity of New South WalesDarlinghurstNSWAustralia
| | - Darren M. Roberts
- Department of Clinical Pharmacology and ToxicologySt Vincent's HospitalDarlinghurstNSWAustralia
- St Vincent's Clinical SchoolUniversity of New South WalesDarlinghurstNSWAustralia
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Carland JE, Smith FC, Day RO. Lactic Acidosis, Metformin Use, and Dose-Response Association. JAMA Intern Med 2018; 178:1428-1429. [PMID: 30285133 DOI: 10.1001/jamainternmed.2018.4448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
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Chiew AL, Wright DFB, Dobos NM, McArdle K, Mostafa AA, Newth A, Roberts MS, Isbister GK. 'Massive' metformin overdose. Br J Clin Pharmacol 2018. [PMID: 29534338 DOI: 10.1111/bcp.13582] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Massive metformin overdose can cause metabolic acidosis with hyperlactatemia. A 55-year-old woman presented 5 h after multidrug overdose, including 132 g extended-release metformin. Continuous venovenous haemodiafiltration (CVVHDF) and noradrenaline were commenced due to metabolic acidosis (pH 7.0, lactate 17 mmol l-1 ) and shock. Despite 3 h of CVVHDF, her acidosis worsened (pH 6.83, lactate 24 mmol l-1 ). Intermittent haemodialysis (IHD) improved acidosis (pH 7.13, lactate 26 mmol l-1 ) but again worsened (pH 6.91, lactate 30 mmol l-1 ) with CVVHDF recommencement. IHD (12 h), CVVHDF (26 h) and vasopressor support for 7 days resulted in survival. Measured metformin concentrations were extremely high with a peak of 292 μg ml-1 at 8 h postingestion. IHD, but not CVVHDF in this case, was associated with improvement in metabolic acidosis and hyperlactataemia. Pharmacokinetic analysis of metformin concentrations found a reduced apparent oral clearance of 8.2 l h-1 and a half-life of approximately 30 h. During IHD, the apparent oral clearance increased to 22.2 l h-1 with an approximate half-life of 10 h. The impact of prolonged oral absorption from a pharmacobezoar and redistribution of metformin from peripheral sites (including erythrocytes) on the pharmacokinetic profile cannot be determined from the data available.
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Affiliation(s)
- Angela L Chiew
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | | | - Nicola M Dobos
- Intensive Care Unit, Western Health, Melbourne, Victoria, Australia
| | - Kylie McArdle
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Ahmed A Mostafa
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Pharmaceutical Chemistry Department, Helwan University, Helwan, Egypt
| | - Annemarie Newth
- Emergency Department and Victorian Poisons Information Centre, The Austin Hospital, Melbourne, Victoria, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Translational Research Institute, Diamantina Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Clinical Toxicology Research Group, University of Newcastle, Callaghan, New South Wales, Australia
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Day RO. Addendum Regarding “Pharmacokinetics of Metformin in Patients Receiving Regular Hemodiafiltration” (Am J Kidney Dis. 2016:68[6]:990-992). Am J Kidney Dis 2017. [DOI: 10.1053/j.ajkd.2017.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kumar SS, Graham GG, Smith FC, Furlong TJ, Greenfield JR, Stocker SS, Carland JE, Day RO. Could metformin be used in patients with advanced chronic kidney disease? Diabetes Obes Metab 2017; 19:302-303. [PMID: 27735109 DOI: 10.1111/dom.12806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 10/07/2016] [Accepted: 10/07/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Shaun S Kumar
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | | | - Jerry R Greenfield
- Diabetes and Metabolism Research Division, Garvan Institute of Medical Research, Sydney, Australia
- St Vincent's Clinical School, UNSW Medicine, St Vincent's Hospital, Sydney, Australia
| | - Sophie S Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
- School of Medical Sciences, UNSW Medicine, University of New South Wales, Kensington, New South Wales, Australia
- St Vincent's Clinical School, UNSW Medicine, St Vincent's Hospital, Sydney, Australia
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