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Barsotti GC, Luciano R, Kumar A, Meliambro K, Kakade V, Tokita J, Naik A, Fu J, Peck E, Pell J, Reghuvaran A, Tanvir E, Patel P, Zhang W, Li F, Moeckel G, Perincheri S, Cantley L, Moledina DG, Wilson FP, He JC, Menon MC. Rationale and Design of a Phase 2, Double-blind, Placebo-Controlled, Randomized Trial Evaluating AMP Kinase-Activation by Metformin in Focal Segmental Glomerulosclerosis. Kidney Int Rep 2024; 9:1354-1368. [PMID: 38707807 PMCID: PMC11068976 DOI: 10.1016/j.ekir.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Focal segmental glomerulosclerosis (FSGS), the most common primary glomerular disease leading to end-stage kidney disease (ESKD), is characterized by podocyte injury and depletion, whereas minimal change disease (MCD) has better outcomes despite podocyte injury. Identifying mechanisms capable of preventing podocytopenia during injury could transform FSGS to an "MCD-like" state. Preclinical data have reported conversion of an MCD-like injury to one with podocytopenia and FSGS by inhibition of AMP-kinase (AMPK) in podocytes. Conversely, in FSGS, AMPK-activation using metformin (MF) mitigated podocytopenia and azotemia. Observational studies also support beneficial effects of MF on proteinuria and chronic kidney disease (CKD) outcomes in diabetes. A randomized controlled trial (RCT) to test MF in podocyte injury with FSGS has not yet been conducted. Methods We report the rationale and design of phase 2, double-blind, placebo-controlled RCT evaluating the efficacy and safety of MF as adjunctive therapy in FSGS. By randomizing 30 patients with biopsy-confirmed FSGS to MF or placebo (along with standard immunosuppression), we will study mechanistic biomarkers that correlate with podocyte injury or depletion and evaluate outcomes after 6 months. We specifically integrate novel urine, blood, and tissue markers as surrogates for FSGS progression along with unbiased profiling strategies. Results and Conclusion Our phase 2 trial will provide insight into the potential efficacy and safety of MF as adjunctive therapy in FSGS-a crucial step to developing a larger phase 3 study. The mechanistic assays here will guide the design of other FSGS trials and contribute to understanding AMPK activation as a potential therapeutic target in FSGS. By repurposing an inexpensive agent, our results will have implications for FSGS treatment in resource-poor settings.
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Affiliation(s)
- Gabriel C. Barsotti
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Randy Luciano
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ashwani Kumar
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kristin Meliambro
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijayakumar Kakade
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Joji Tokita
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abhijit Naik
- Division of Nephrology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Jia Fu
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elizabeth Peck
- Clinical Research Coordinator, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Pell
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anand Reghuvaran
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - E.M. Tanvir
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Prashant Patel
- Investigational Drug Service, Department of Pharmacy Services, Yale New Haven Hospital, Connecticut, USA
| | - Weijia Zhang
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Gilbert Moeckel
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sudhir Perincheri
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lloyd Cantley
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dennis G. Moledina
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - F. Perry Wilson
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John C. He
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madhav C. Menon
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Yu Q, Zhu JJ, Liu WX. Effect of continuous use of metformin on kidney function in diabetes patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. BMC Cardiovasc Disord 2020; 20:187. [PMID: 32316910 PMCID: PMC7175536 DOI: 10.1186/s12872-020-01474-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/12/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Diabetes patients presenting with ST-segment elevation myocardial infarction (STEMI) scheduled for primary percutaneous coronary intervention (PCI) have an increased risk of contrast induced-acute kidney injury (CI-AKI). The effects of continuous use of metformin on kidney function are still controversial in patients submitted to primary PCI. This study aimed to assess continuous metformin therapy on kidney function in diabetic patients undergoing coronary intervention. METHODS Two hundred eighty-four patients with metformin-treated diabetes, who underwent coronary intervention within 24 h for STEMI, were enrolled in the retrospective study. All the patients had estimated glomerular filtration rate (eGFR) of > 30 mL/min/1.73 m2. According to the physicians' decisions after admission, 119 patients continued metformin treatment after primary PCI, while 165 patients discontinued it > 48 h after the procedure. Serum creatinine was collected at admission and within 48 h post primary PCI to evaluate the incidence of CI-AKI. We performed a multiple logistic regression analysis to examine the determinants of CI-AKI. RESULTS No statistical difference in CI-AKI incidence between the continuous and the discontinuous metformin group (12.6%vs10.3%, p = 0.545). Multivariable logistic regression analysis indicated eGFR ≤60 ml/min/1.73 m2[p = 0.025, OR: 3.131; 95% CI (1.156-8.482)] and contrast volume [p = 0.002, OR: 1.010; 95% CI (1.004-1.016)] were predictive factors of CI-AKI. Metformin therapy was irrelevant to CI-AKI [p = 0.365, OR: 0.698; 95% CI (0.320-1.521)]. No case of lactic acidosis was found in this study. Besides, the study supported discontinuation of metformin was not beneficial for patients' blood glucose control after admission. CONCLUSIONS The study indicated that the metformin continuation after primary PCI for STEMI in diabetic patients with eGFR > 30 ml/min / 1.73 m2 did not increase the risk of CI-AKI.
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Affiliation(s)
- Qi Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
| | - Jia-Jia Zhu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
| | - Wen-Xian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029 China
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Jung J, Cho YY, Jung JH, Kim KY, Kim HS, Baek JH, Hahm JR, Cho HS, Kim SK. Are patients with mild to moderate renal impairment on metformin or other oral anti-hyperglycaemic agents at increased risk of contrast-induced nephropathy and metabolic acidosis after radiocontrast exposure? Clin Radiol 2019; 74:651.e1-651.e6. [PMID: 31202566 DOI: 10.1016/j.crad.2019.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
AIM To investigate whether the use of metformin during computed tomography (CT) with radiocontrast agents increases the risk of contrast-induced nephropathy (CIN) and metabolic acidosis after CT in type 2 diabetes patients with mild to moderate renal failure. MATERIALS AND METHODS Patient records from January 2015 to December 2017 were reviewed retrospectively. A total of 374 patients were included in the final analysis. Of them, 157 patients received metformin, and 217 patients were taking other oral hypoglycaemic agents (OHAs) during radiocontrast administration. RESULTS No significant difference in CIN incidence was observed between the metformin use group and the other OHAs group (p=0.085). Metabolic acidosis after CT was seen in 91 (58%) patients who used metformin and 141 (65%) patients who were taking other OHAs. There was no relationship between metabolic acidosis after CT and the use of metformin (p=0.195). Metabolic acidosis after radiocontrast agent exposure was associated with malignant disease, low serum albumin level, and low serum total CO2 level at baseline. CONCLUSION These data show that other factors, but not metformin use, are associated with metabolic acidosis after radiocontrast agent exposure in patients with reduced renal function. These data support current recommendations that there is no need to discontinue metformin before CT using radiocontrast agents in patients with mild to moderate renal failure.
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Affiliation(s)
- J Jung
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Y Y Cho
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - J H Jung
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - K Y Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - H S Kim
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - J-H Baek
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - J R Hahm
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - H S Cho
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - S K Kim
- Gyeongsang National University School of Medicine Jinju, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea; Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea.
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Malik F, Mehdi SF, Ali H, Patel P, Basharat A, Kumar A, Ashok F, Stein J, Brima W, Malhotra P, Roth J. Is metformin poised for a second career as an antimicrobial? Diabetes Metab Res Rev 2018; 34:e2975. [PMID: 29271563 DOI: 10.1002/dmrr.2975] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 12/24/2022]
Abstract
Metformin, a widely used antihyperglycaemic, has a good safety profile, reasonably manageable side-effects, is inexpensive, and causes a desirable amount of weight loss. In 4 studies of patients with tuberculosis (1 prospective and 3 retrospective), metformin administration resulted in better outcomes. In mice with several models of endotoxemia, metformin diminished levels of proinflammatory cytokines and improved survival. Laboratory studies showed effectiveness of the drug on multiple pathogens, including Trichinella spiralis, Staphylococcus aureus, Pseudomonas aeruginosa, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. Metformin administration in humans and mice produced major changes in the composition of the gut microbiota. These recently discovered microbe-modulating properties of the drug have led investigators to predict wide therapeutic utility for metformin. The recent easing in United States Food and Drug Administration (FDA) guidelines regarding administration of metformin to patients with kidney disease, and reduced anxiety about patient safety in terms of lactic acidosis, increase the probability of broadening of metformin's usage as a treatment of infectious agents. In this text we review articles pertinent to metformin's effects on microorganisms, both pathogens and commensals. We highlight the possible role of metformin in a wide range of infectious diseases and a possible expansion of its therapeutic profile in this field. A systematic review was done of PubMed indexed articles that examined the effects of metformin on a wide range of pathogens. Metformin was found to have efficacy as an antimicrobial agent in patients with tuberculosis. Mice infected with Trypanosomiasis cruzi had higher survival when also treated with metformin. The drug in vitro was active against T. spiralis, S. aureus, P. aeruginosa, and hepatitis B virus. In addition there is emerging literature on its role in sepsis. We conclude that metformin may have a potential role in the therapy for multiple infectious diseases. Metformin, in addition to its traditional effects on glucose metabolism, provides anti-microbial benefits in patients with tuberculosis and in a very wide range of other infections encounters in vitro and in vivo.
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Affiliation(s)
- Faiza Malik
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Syed Faizan Mehdi
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Haroon Ali
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Priya Patel
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Anam Basharat
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Amrat Kumar
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Fnu Ashok
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Joanna Stein
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Wunnie Brima
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Prashant Malhotra
- Division of Infectious Diseases, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jesse Roth
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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Abstract
Metformin has been associated with lactic acidosis. Lactate levels are not commonly tested in clinical practice, and it is unclear to what extent metformin would typically increase lactate levels with chronic use. The aim of this review was to determine whether regular monitoring of the plasma lactate level would be beneficial in avoiding lactate accumulation and, ultimately, minimising the incidence of lactic acidosis in metformin-treated patients.A comprehensive search of PubMed, Embase, Web of Science, Cochrane and International Pharmaceutical Abstracts databases covering the period up to 30 May 2017 was performed. Search terms included combinations of terms and keywords, including "metformin", "lactate", "lactic acid" and "lactic acidosis". Cases series of lactic acidosis or metformin-associated lactic acidosis were excluded.Of 1539 potentially relevant articles, a total of 52 reported lactate levels from routine/regular pathological tests in metformin users. The studies were subdivided into four themes, regarding metformin usage and the reported lactate levels in patients who: (1) did not have contraindications to the use of metformin; (2) had contraindications, or renal impairment but without other contraindications; (3) exercised; or (4) also received any nucleoside reverse transcriptase inhibitor. Studies have reported that metformin treatment could increase lactate level of users. However, most results showed that the lactate level remained in the normal range.No definitive conclusions on the benefits of regular lactate monitoring in patients taking metformin can be made. Future research on larger populations focusing on the measurement of lactate levels with continuous metformin use is warranted.
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Lee EY, Hwang S, Lee YH, Lee SH, Lee YM, Kang HP, Han E, Lee W, Lee BW, Kang ES, Cha BS, Lee HC. Association between Metformin Use and Risk of Lactic Acidosis or Elevated Lactate Concentration in Type 2 Diabetes. Yonsei Med J 2017; 58:312-318. [PMID: 28120561 PMCID: PMC5290010 DOI: 10.3349/ymj.2017.58.2.312] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 07/05/2016] [Accepted: 08/23/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Metformin can reduce diabetes-related complications and mortality. However, its use is limited because of potential lactic acidosis-associated adverse effects, particularly in renal impairment patients. We aimed to investigate the association of metformin use with lactic acidosis and hyperlactatemia in patients with type 2 diabetes. MATERIALS AND METHODS This was a cross-sectional study from a tertiary university-affiliated medical center. A total of 1954 type 2 diabetes patients were recruited in 2007-2011, and stratified according to the estimated glomerular filtration rate of 60 mL/min/1.73 m². Lactic acidosis was defined as plasma lactate levels >5 mmol/L and arterial pH <7.35. RESULTS Metformin was used in 61.4% of the patients with type 2 diabetes mellitus. Plasma lactate levels were not different in the patients with and without metformin use. There was no difference in prevalence of hyperlactatemia and lactic acidosis between the patients with and without metformin use (18.9% vs. 18.7%, p=0.905 for hyperlactatemia and 2.8% vs. 3.3%, p=0.544 for lactic acidosis). Similar results were observed in the patients with estimated glomerular filtration rate <60 mL/min/1.73 m². Most patients with lactic acidosis had at least one condition related to hypoxia or poor tissue perfusion. Multiple regression analysis indicated no association between metformin use and lactic acidosis, whereas tissue hypoxia was an independent risk factor for lactic acidosis [odds ratio 4.603 (95% confidence interval, 1.327-15.965)]. CONCLUSION Metformin use was not associated with hyperlactatemia or lactic acidosis in patients with type 2 diabetes.
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Affiliation(s)
- Eun Young Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sena Hwang
- Chaum Life Center, CHA University School of Medicine, Seoul, Korea
| | - Yong Ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seo Hee Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Mi Lee
- Department of Internal Medicine, Dongtan Jeil Women's Hospital, Hwasung, Korea
| | - Hua Pyong Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eugene Han
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Woonhyoung Lee
- Department of Laboratory Medicine, Kosin University College of Medicine, Busan, Korea
| | - Byung Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Bong Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Chul Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Yokoyama S, Tsuji H, Hiraoka S, Nishihara M. Investigation of Risk Factors Affecting Lactate Levels in Japanese Patients Treated with Metformin. Biol Pharm Bull 2017; 39:2022-2027. [PMID: 27904044 DOI: 10.1248/bpb.b16-00517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Metformin is a biguanaide antidiabetic drug used worldwide, and its effectiveness and benefits have already been established. However, the safety of high doses of metformin in Japanese patients, especially in elderly patients with a decreased renal function, remains unclear. Among the side effects of metformin, lactate acidosis is the most problematic due to a high mortality rate. Therefore, we assessed plasma lactate levels in metformin-treated patients to identify independent risk factors for hyperlactemia. 290 outpatients receiving various doses of metformin at our hospital were enrolled between March and July 2014. Serum electrolytes, Cre (creatinine), BUN (blood urea nitrogen), UA (uric acid), HbA1c (hemoglobin A1c), and lactate levels were investigated. Lactate levels did not significantly differ between the elderly (≥75 years) and non-elderly (<75 years) groups. Patients in the elderly group had a significantly lower daily metformin dose and estimated glomerular filtration rate (eGFR), compared with the non-elderly group (both p<0.005). Between with and without hyperlactemia groups, no significant differences were observed in either Cre or age. On the other hand, patients with hyperlactemia had a significantly higher dose of metformin than those without hyperlactemia (p<0.05). In this study, we found that old age and mildly impaired kidney function were not associated with increased lactate levels, and that a higher dose of metformin may be an independent risk factor for elevated lactate levels in Japanese patients.
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Affiliation(s)
- Shota Yokoyama
- Department of Pharmacy, Mazda Hospital of Mazda Motor Corporation
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Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, del Cañizo-Gómez FJ. Update on the treatment of type 2 diabetes mellitus. World J Diabetes 2016; 7:354-95. [PMID: 27660695 PMCID: PMC5027002 DOI: 10.4239/wjd.v7.i17.354] [Citation(s) in RCA: 326] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/02/2016] [Accepted: 07/20/2016] [Indexed: 02/05/2023] Open
Abstract
To achieve good metabolic control in diabetes and keep long term, a combination of changes in lifestyle and pharmacological treatment is necessary. Achieving near-normal glycated hemoglobin significantly, decreases risk of macrovascular and microvascular complications. At present there are different treatments, both oral and injectable, available for the treatment of type 2 diabetes mellitus (T2DM). Treatment algorithms designed to reduce the development or progression of the complications of diabetes emphasizes the need for good glycaemic control. The aim of this review is to perform an update on the benefits and limitations of different drugs, both current and future, for the treatment of T2DM. Initial intervention should focus on lifestyle changes. Moreover, changes in lifestyle have proven to be beneficial, but for many patients is a complication keep long term. Physicians should be familiar with the different types of existing drugs for the treatment of diabetes and select the most effective, safe and better tolerated by patients. Metformin remains the first choice of treatment for most patients. Other alternative or second-line treatment options should be individualized depending on the characteristics of each patient. This article reviews the treatments available for patients with T2DM, with an emphasis on agents introduced within the last decade.
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Abstract
Type 2 diabetic patients often exhibit hyperlactatemia in association with a reduced aerobic-oxidative capacity and a restricted lactate transport. Studies suggest a link between increased lactate levels and the manifestation and progression of insulin resistance. However, the specificities of molecular mechanisms remain unclear, and it is not entirely clear whether elevated lactate levels are a cause or consequence of type 2 diabetes. This review focuses on lactate as a key molecule in diabetes and provides an overview of how regular physical activity can be helpful in normalizing elevated lactate levels in type 2 diabetic patients. Physical training may reduce lactate production and reinforce lactate transport and clearance among this particular patient group. We emphasize the crucial role physical training plays in the therapy of type 2 diabetes due to evidence that pharmacological treatment with metformin, which is commonly used in the first-line therapy of type 2 diabetes, does not help reducing lactate levels.
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Affiliation(s)
- Christian Brinkmann
- Institute of Cardiovascular Research and Sport Medicine, Department of Molecular and Cellular Sport Medicine, German Sport University Cologne, Cologne, Germany.
| | - Klara Brixius
- Institute of Cardiovascular Research and Sport Medicine, Department of Molecular and Cellular Sport Medicine, German Sport University Cologne, Cologne, Germany
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Abstract
IMPORTANCE Metformin is widely viewed as the best initial pharmacological option to lower glucose concentrations in patients with type 2 diabetes mellitus. However, the drug is contraindicated in many individuals with impaired kidney function because of concerns of lactic acidosis. OBJECTIVE To assess the risk of lactic acidosis associated with metformin use in individuals with impaired kidney function. EVIDENCE ACQUISITION In July 2014, we searched the MEDLINE and Cochrane databases for English-language articles pertaining to metformin, kidney disease, and lactic acidosis in humans between 1950 and June 2014. We excluded reviews, letters, editorials, case reports, small case series, and manuscripts that did not directly pertain to the topic area or that met other exclusion criteria. Of an original 818 articles, 65 were included in this review, including pharmacokinetic/metabolic studies, large case series, retrospective studies, meta-analyses, and a clinical trial. RESULTS Although metformin is renally cleared, drug levels generally remain within the therapeutic range and lactate concentrations are not substantially increased when used in patients with mild to moderate chronic kidney disease (estimated glomerular filtration rates, 30-60 mL/min per 1.73 m2). The overall incidence of lactic acidosis in metformin users varies across studies from approximately 3 per 100,000 person-years to 10 per 100,000 person-years and is generally indistinguishable from the background rate in the overall population with diabetes. Data suggesting an increased risk of lactic acidosis in metformin-treated patients with chronic kidney disease are limited, and no randomized controlled trials have been conducted to test the safety of metformin in patients with significantly impaired kidney function. Population-based studies demonstrate that metformin may be prescribed counter to prevailing guidelines suggesting a renal risk in up to 1 in 4 patients with type 2 diabetes mellitus--use which, in most reports, has not been associated with increased rates of lactic acidosis. Observational studies suggest a potential benefit from metformin on macrovascular outcomes, even in patients with prevalent renal contraindications for its use. CONCLUSIONS AND RELEVANCE Available evidence supports cautious expansion of metformin use in patients with mild to moderate chronic kidney disease, as defined by estimated glomerular filtration rate, with appropriate dosage reductions and careful follow-up of kidney function.
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Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Kasia J Lipska
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Helen Mayo
- Health Sciences Digital Library and Learning Center, University of Texas Southwestern Medical Center, Dallas
| | - Clifford J Bailey
- School of Life & Health Sciences, Aston University, Birmingham, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
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Eppenga WL, Lalmohamed A, Geerts AF, Derijks HJ, Wensing M, Egberts A, De Smet PAGM, de Vries F. Risk of lactic acidosis or elevated lactate concentrations in metformin users with renal impairment: a population-based cohort study. Diabetes Care 2014; 37:2218-24. [PMID: 24842984 DOI: 10.2337/dc13-3023] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to determine whether treatment with metformin in patients with renal impairment is associated with a higher risk of lactic acidosis or elevated lactate concentrations compared with users of a noninsulin antidiabetic drug (NIAD) who had never used metformin. RESEARCH DESIGN AND METHODS A cohort of 223,968 metformin users and 34,571 diabetic patients who had never used metformin were identified from the Clinical Practice Research Datalink (CPRD).The primary outcome was defined as either a CPRD READ code lactic acidosis or a record of a plasma lactate concentration >5 mmol/L. The associations between renal impairment, dose of metformin, and the risk of lactic acidosis or elevated lactate concentrations were determined with time-dependent Cox models and expressed as hazard ratios (HRs). RESULTS The crude incidence of lactic acidosis or elevated lactate concentrations in current metformin users was 7.4 per 100,000 person-years (vs. 2.2 per 100,000 person-years in nonusers). Compared with nonusers, risk of lactic acidosis or elevated lactate concentrations in current metformin users was significantly associated with a renal function <60 mL/min/1.73 m(2) (adjusted HR 6.37 [95% CI 1.48-27.5]). The increased risk among patients with impaired renal function was further increased in users of ≥730 g of metformin in the preceding year (adjusted HR 11.8 [95% CI 2.27-61.5]) and in users of a recent high daily dose (>2 g) of metformin (adjusted HR 13.0 [95% CI 2.36-72.0]). CONCLUSIONS Our study is consistent with current recommendations that the renal function of metformin users should be adequately monitored and that the dose of metformin should be adjusted, if necessary, if renal function falls below 60 mL/min/1.73 m(2).
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Affiliation(s)
- Willemijn L Eppenga
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Center, Nijmegen, the NetherlandsHospital Pharmacy 'ZANOB', 's-Hertogenbosch, the Netherlands
| | - Arief Lalmohamed
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the NetherlandsDepartment of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arjen F Geerts
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the Netherlands
| | - Hieronymus J Derijks
- Hospital Pharmacy 'ZANOB', 's-Hertogenbosch, the NetherlandsDivision of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the Netherlands
| | - Michel Wensing
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Antoine Egberts
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the NetherlandsDepartment of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter A G M De Smet
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Center, Nijmegen, the NetherlandsDepartment of Clinical Pharmacy, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Frank de Vries
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, the NetherlandsDepartment of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, the NetherlandsCare and Public Health Research Institute (CAPHRI), Maastricht, the Netherlands
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Kang YJ, Bae EJ, Seo JW, Jeon DH, Cho HS, Kim HJ, Chang SH, Park DJ. Two additional cases of metformin-associated encephalopathy in patients with end-stage renal disease undergoing hemodialysis. Hemodial Int 2012; 17:111-5. [DOI: 10.1111/j.1542-4758.2012.00698.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Yeo-Jin Kang
- Department of Internal Medicine; School of Medicine Gyeongsang National University; Jinju City; Gyeongsangnam-do; South Korea
| | - Eun Jin Bae
- Department of Internal Medicine; School of Medicine Gyeongsang National University; Jinju City; Gyeongsangnam-do; South Korea
| | - Jong Woo Seo
- Department of Internal Medicine; School of Medicine Gyeongsang National University; Jinju City; Gyeongsangnam-do; South Korea
| | - Dae-Hong Jeon
- Department of Internal Medicine; School of Medicine Gyeongsang National University; Jinju City; Gyeongsangnam-do; South Korea
| | - Hyun Seop Cho
- Department of Internal Medicine; School of Medicine Gyeongsang National University; Jinju City; Gyeongsangnam-do; South Korea
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13
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Affiliation(s)
- Kasia J. Lipska
- Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
| | - Clifford J. Bailey
- Department of Life and Health Sciences, Aston University, Birmingham, U.K
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
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14
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Lin YC, Lin LY, Wang HF, Lin HD. Fasting plasma lactate concentrations in ambulatory elderly patients with type 2 diabetes receiving metformin therapy: a retrospective cross-sectional study. J Chin Med Assoc 2010; 73:617-22. [PMID: 21145508 DOI: 10.1016/s1726-4901(10)70135-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 07/30/2010] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Metformin is a worldwide accepted biguanide antidiabetic agent, and its effectiveness and benefit have already been well established. Among the side effects of metformin, lactate acidosis is the most problematic because of a high mortality rate, which impedes its use in clinical practice, especially in elderly patients with type 2 diabetes. Aging is associated with a decreased renal function and increasing comorbidities, but few data are available regarding plasma lactate levels in this unique population. In this study, we assessed fasting plasma lactate levels in ambulatory, elderly Taiwanese patients with type 2 diabetes, who were taking the drug, metformin, to identify independent risk factors for hyperlactemia in this group. METHODS Sixty-six ambulatory type 2 diabetic patients, > 80 years of age (mean, 83.6 years; range, 80-90 years), receiving metformin therapy, were enrolled, from January 2005 to September 2009, in the Diabetes Case Management Program. A further 79 younger patients (also type 2 diabetics on metformin) served as controls (mean age, 59.9 years; range, 37-79 years). Fasting serum electrolytes, creatinine, bicarbonate, glycated hemoglobin, plasma glucose and lactate levels were determined. RESULTS Lactate levels did not differ between the elderly and control groups (13.2 +/- 5.2 mg/dL and 13.5 +/- 4.8 mg/dL, respectively). None of the patients fulfilled the lactic acidosis criteria. Patients in the elderly group had a significantly lower daily metformin dose, higher creatinine levels, and lower estimated creatinine clearance, compared with the control group (all p < 0.05). Estimated creatinine clearance was negatively associated with lactate levels in the elderly group (p < 0.05, r = -0.27), but not in the control group. Patients with fasting plasma glucose levels > 130 mg/dL had a 2.8-fold increased risk of developing hyperlactemia. CONCLUSION Plasma lactate levels in ambulatory elderly patients with type 2 diabetes receiving metformin therapy did not differ from those in a younger age group. Patients with fasting plasma glucose levels > 130 mg/dL had a 2.8-fold risk of developing hyperlactemia, but none of them developed lactate acidosis.
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Affiliation(s)
- Yi-Chun Lin
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, and National Yang-Ming University, Taipei, Taiwan, R.O.C
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15
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Bando K, Ochiai S, Kunimatsu T, Deguchi J, Kimura J, Funabashi H, Seki T. Comparison of potential risks of lactic acidosis induction by biguanides in rats. Regul Toxicol Pharmacol 2010; 58:155-60. [DOI: 10.1016/j.yrtph.2010.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 05/13/2010] [Accepted: 05/14/2010] [Indexed: 11/24/2022]
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16
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Papanas N, Monastiriotis C, Christakidis D, Maltezos E. Metformin and lactic acidosis in patients with type 2 diabetes--from pride and prejudice to sense and sensibility. Acta Clin Belg 2009; 64:42-8. [PMID: 19317240 DOI: 10.1179/acb.2009.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
AIM To present the cases of lactic acidosis encountered in our department among metformin-treated type 2 diabetic patients and to investigate the role of contraindications to metformin use. METHODS A survey of medical records of metformin-treated type 2 diabetic patients hospitalised for various medical conditions during the years 2004-2005 who exhibited elevated serum concentrations of lactic acid. RESULTS Seven metformin-treated type 2 diabetic patients were identified who were not attending our department and were hospitalised with elevated serum lactic acid levels (6 developed lactic acidosis). All patients had one or more contraindications to metformin use. Outcome was favourable in 6 patients, while 1 patient with hepatocellular carcinoma died of liver failure. CONCLUSIONS So far, metformin is one of the safest first-line oral hypoglycaemic agents. However, caution is needed to avoid patients with evident contraindications. This highlights the need for the practitioner to possess sound clinical judgement when prescribing metformin.
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Affiliation(s)
- N Papanas
- Second Department of Internal Medicine, Democritus University of Thrace, Greece.
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Abstract
Metformin is associated with decreased mortality and morbidity in stable heart failure patients with diabetes mellitus type II. Diabetic heart failure patients with elevated systolic blood pressure are at increased risk for developing acute decompensated heart failure, which is often associated with decreased kidney function. Metformin-associated lactic acidosis is a rare but fatal side effect that may occur when kidney function is decreased. During acute decompensated heart failure, timely treatment may prevent the decrease in kidney function to the threshold associated with an increased risk of metformin-associated lactic acidosis. Metformin should not be withheld in diabetic patients with stable heart failure who do not have other risk factors for acute decompensated heart failure or lactic acidosis.
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Affiliation(s)
- Alex Boyd
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
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