Effect of continuous use of metformin on kidney function in diabetes patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

Appraisal of guidelines for managing contrast medium in patients with metformin: consensuses, controversies, and gaps

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.

Primary PCI and Mental Health: A 12-Month Follow-Up Study

The research article highlights the significance of acute myocardial infarction (AMI) and its impact on depression and anxiety among patients' post-primary percutaneous coronary interventions (PCI). The study aims to determine the frequency of depression and anxiety occurrence in patients with acute myocardial infarction after primary PCI. The objective of this study is to investigate the frequency of depression and anxiety in patients with acute myocardial infarction after primary PCI. The method used in the study involved the collection of data from 88 patients with acute myocardial infarction who underwent primary PCI treatment. The patients were tested before PCI and then at intervals of 1 month, 6 months, and 12 months post-PCI using the Hamilton Depression Scale (HAM-D17) and the Hamilton Anxiety Scale (HAM-A) to identify depression and anxiety symptoms, respectively. The study performed a comprehensive analysis of the collected data to determine the frequency of depression and anxiety occurrence in post-PCI patients. The study found evidence that primary PCI reduces depression and anxiety in patients who have experienced a myocardial infarction. However, mental health issues continue to be a significant psychological concern for patients post-PCI, impacting their lifestyle, self-care, and treatment adherence. The study suggests that healthcare providers should actively screen and manage psychiatric disorders in patients who have suffered from AMI as they are at an increased risk of mental disorders. In conclusion, the study indicates that depression and anxiety are common issues in acute myocardial infarction survivors, and interventions addressing these conditions should be a routine part of care. The study highlights the need for healthcare providers to be aware of the increased risk of mental disorders in individuals who have suffered from AMI. Understanding the impact of anxiety and depression on post-PCI patients is essential for the development of effective interventions that support patients' recovery.

[Use of metformin in patients with type 2 diabetes and acute myocardial infarction: safety and impact on glycemic control]

BACKGROUND

Myocardial infarction (MI) in patients with diabetes type 2 (T2DM) occurs 1.5-3.0 times higher than in general population. Metformin is contraindicated for patients with T2DM and acute coronary syndrome due to the risk of developing lactic acidosis. Using metformin more than 48 hours of MI is a topical question, which will help to improve patient's safety.

AIM

To evaluate the safety and quality of glycemic control using metformin in patients with T2DM during inpatient treatment for MIMATERIALS AND METHODS: The study included 161 patients with T2DM, who were hospitalized consecutively with acute MI with ST-elevation and underwent percutaneous coronary intervention (PCI). Average time of metformin initiation was 5th day from admission. Creatinine was assessed at admission and 48 hours after PCI. The acid-base balance and lactate were assessed at admission and on the 3rd day after the start of using metformin. Criteria for the effectiveness of glycemic control was the proportion of glycemic measurements in target range of 6.1-10.0 mmol/l during hospitalization ("hospital time in range", hTIR). hTIR >55% was considered to be a critical level. The long-term outcome was estimated at 365 days after hospitalization.

RESULTS

Metformin was prescribed to 99 patients (61%) ("M+"group) during the hospitalization, 62 patients were in "M-"group. Use of metformin was accompanied with better glycemic control in the «M+» group compared to the «M-»: mean glycemia 9.3 ± 1.6 vs 10.3 ± 2.3 mmol/l (p=0,002), SD 2.87 ± 1.1 vs 3.26 ± 1.8 (p=0,049), hTIR 60 ± 18% vs 48 ± 23% (p<0,001). There were clinically insignificant changes in acid-base balance on the 3rd day from the start of metformin use in the "M+" group, the lactate level did not increase. Use of metformin before to hospitalization with MI was not associated with an increased risk of developing acute kidney injury (AKI): RR 0.85 (0.37-1.96), p=0,691.

CONCLUSION

Use of metformin in patients with T2DM and acute MI is associated with better glycemic control. Carrying out angiography in patients, treated with metformin before the hospitalization, is not accompanied by an increased risk of developing AKI. Appointment of metformin in 3-7 days after angiography does not lead to an increase level of lactate and significant deviations in acid-base balance.

Safety of metformin continuation in diabetic patients undergoing invasive coronary angiography: the NO-STOP single arm trial

BACKGROUND

Despite paucity of data, it is common practice to discontinue metformin before invasive coronary angiography due to an alleged risk of Metformin-Associated Lactic Acidosis (M-ALA). We aimed at assessing the safety of metformin continuation in diabetic patients undergoing coronary angiography in terms of significant increase in lactate levels.

METHODS

In this open-label, prospective, multicentre, single-arm trial, all diabetic patients undergoing coronary angiography with or without percutaneous coronary intervention at 3 European centers were screened for enrolment. The primary endpoint was the increase in lactate levels from preprocedural levels at 72-h after the procedure. Secondary endpoints included contrast associated-acute kidney injury (CA-AKI), M-ALA, and all-cause mortality.

RESULTS

142 diabetic patients on metformin therapy were included. Median preprocedural lactate level was 1.8 mmol/l [interquartile range (IQR) 1.3-2.3]. Lactate levels at 72 h after coronary angiography were 1.7 mmol/l (IQR 1.3-2.3), with no significant differences as compared to preprocedural levels (p = 0.91; median difference = 0; IQR - 0.5 to 0.4 mmol/l). One patient had 72-h levels ≥ 5 mmol/l (5.3 mmol/l), but no cases of M-ALA were reported. CA-AKI occurred in 9 patients (6.1%) and median serum creatinine and estimated glomerular filtration rate remained similar throughout the periprocedural period. At a median follow-up of 90 days (43-150), no patients required hemodialysis and 2 patients died due to non-cardiac causes.

CONCLUSIONS

In diabetic patients undergoing invasive coronary angiography, metformin continuation throughout the periprocedural period does not increase lactate levels and was not associated with any decline in renal function.

TRIAL REGISTRATION

The study was registered at Clinicaltrials.gov (NCT04766008).

Metformin Can Be Safely Used in Patients Exposed to Contrast Media: A Systematic Review and Meta-Analysis

BACKGROUND

There have been few studies published on the use of contrast media (CM) in metformin-treated patients. In this study, we conducted a systematic review and meta-analysis to investigate the relationship between metformin and contrast-induced acute kidney injury (CI-AKI).

METHODS

A comprehensive search of the Medline, PubMed, Embase, and Web of Science databases for literature on associations between metformin use and CI-AKI incidence was conducted. The pooled odds ratio (OR), or relative risk, as well as the corresponding 95% confidence intervals (CIs), was calculated to assess the relationship between metformin and CI-AKI risk as well as the incidence of lactic acidosis (LA).

RESULTS

In total, seven studies met our eligibility criteria on associations between metformin use and CI-AKI incidence, comprising 2,325 individuals, with 279 new cases of CI-AKI exposed to CM. The pooled analysis revealed no statistically significant increase in the risk of CI-AKI development in patients who used metformin continuously (random-effects OR: 1.15, 95% CI: 0.70-1.90, p = 0.57). No cases of LA that occurred during CM exposure were reported.

CONCLUSION

Metformin can be safely used in patients with moderate renal impairment (eGFR ≥ 30 mL/min/1.73 m2) during CM exposure.

Safety and Efficacy of Inpatient Diabetes Management with Non-insulin Agents: an Overview of International Practices

PURPOSE OF REVIEW

The field of inpatient diabetes has advanced significantly over the last 20 years, leading to the development of personalized treatment approaches. However, outdated guidelines still recommend the use of basal-bolus insulin therapy as the preferred treatment approach, and against the use of non-insulin anti-hyperglycemic agents.

RECENT FINDINGS

Several observational and prospective randomized controlled studies have demonstrated that oral anti-hyperglycemic agents are widely used in the hospital, including studies of DPP-4 agents and GLP-1 agonists. With advances in the field of inpatient diabetes management, a paradigm shift has occurred, from an approach of recommending "basal-bolus regimens" for all patients to a more precision medicine option for hospitalized non-critically ill patients with type 2 diabetes.

Continuous use of metformin in patients receiving contrast medium: what is the evidence? A systematic review and meta-analysis

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.

Use of Anti-Diabetic Agents in Non-Diabetic Kidney Disease: From Bench to Bedside

New drugs were recently developed to treat hyperglycemia in patients with type 2 diabetes mellitus (T2D). However, metformin remains the first-line anti-diabetic agent because of its cost-effectiveness. It has pleiotropic action that produces cardiovascular benefits, and it can be useful in diabetic nephropathy, although metformin-associated lactic acidosis is a hindrance to its use in patients with kidney failure. New anti-diabetic agents, including glucagon-like peptide-1 receptor (GLP-1R) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose transporter-2 (SGLT-2) inhibitors, also produce cardiovascular or renal benefits in T2D patients. Their glucose-independent beneficial actions can lead to cardiorenal protection via hemodynamic stabilization and inflammatory modulation. Systemic hypertension is relieved by natriuresis and improved vascular dysfunction. Enhanced tubuloglomerular feedback can be restored by SGLT-2 inhibition, reducing glomerular hypertension. Patients with non-diabetic kidney disease might also benefit from those drugs because hypertension, proteinuria, oxidative stress, and inflammation are common factors in the progression of kidney disease, irrespective of the presence of diabetes. In various animal models of non-diabetic kidney disease, metformin, GLP-1R agonists, DPP-4 inhibitors, and SGLT-2 inhibitors were favorable to kidney morphology and function. They strikingly attenuated biomarkers of oxidative stress and inflammatory responses in diseased kidneys. However, whether those animal results translate to patients with non-diabetic kidney disease has yet to be evaluated. Considering the paucity of new agents to treat kidney disease and the minimal adverse effects of metformin, GLP-1R agonists, DPP-4 inhibitors, and SGLT-2 inhibitors, these anti-diabetic agents could be used in patients with non-diabetic kidney disease. This paper provides a rationale for clinical trials that apply metformin, GLP-1R agonists, DPP-4 inhibitors, and SGLT-2 inhibitors to non-diabetic kidney disease.

Effects of continuous use of metformin on cardiovascular outcomes in patients with type 2 diabetes after acute myocardial infarction: A protocol for systematic review and meta-analysis

BACKGROUND

To our knowledge, no meta-analyses or reviews have investigated the efficacy and safety of metformin on cardiovascular outcomes after acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus (T2DM). We thus conduct a high-quality systematic review and meta-analysis to assess the efficacy and safety of metformin on cardiovascular outcomes after AMI in patients with T2DM.

METHODS

In this systematic review and meta-analysis, we will search PUBMED, Scopus, EMBASE, and Cochrane Library databases through April, 2021. The study is structured to adhere to PRISMA guidelines (i.e., Preferred Reporting Items for Systematic Reviews and Meta-analyses). The literature search, data extraction, and quality assessments are conducted independently by 2 authors. Outcome measures include all-cause mortality; complications such as acute kidney injury, lactic acidosis, hospitalization for AMI or stroke, or death. Where disagreement in the collection of data occurs, this is resolved through discussion. Review Manager Software (v 5.3; Cochrane Collaboration) is used for the meta-analysis. Two independent reviewers will assess the risk of bias of the included studies at study level.

RESULTS

It is hypothesized that metformin use at the post-AMI is associated with decreased risk of cardiovascular disease and death in patients with T2DM.

CONCLUSIONS

This study expects to provide credible and scientific evidence for the efficacy and safety of metformin on cardiovascular outcomes after AMI in patients with T2DM.

REGISTRATION NUMBER

10.17605/OSF.IO/S3MBP.