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ESP Report: Metformin Use in Patients with Historical Contraindications or Precautions

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Metformin Use in Patients with Contraindications or Precautions

Principal Investigators: Matthew J. Crowley, MD; Clarissa J. Diamantidis, MD; John W. Williams, Jr, MD, MHSc
Co-Investigators: Jennifer R. McDuffie, PhD; Blake Cameron, MD; John Stanifer, MD; Clare K. Mock, MD; Andrzej Kosinski, PhD; Xianwei Wang, MD; Shuang Tang, MD, PhD;
Research Associates: Avishek Nagi, MS; Liz Wing, MA

Evidence-based Synthesis Program (ESP) Center, Durham VA Medical CenterDurham, Durham, NC

Washington (DC): Department of Veterans Affairs; September 2016


Download PDF: Complete Report, Executive Summary, Report, Appendices, Errata and Corrections

Introduction

Metformin is a biguanide oral hypoglycemic used primarily for treating type 2 diabetes mellitus (T2D). Evidence suggests that, in addition to improving glycemic control, metformin is associated with improved all-cause and cardiovascular mortality and decreased risk of some cancers. However, clinicians have been advised by the U.S. Food and Drug Administration (FDA) to exercise caution in prescribing metformin to individuals with chronic kidney disease (CKD), unstable congestive heart failure (CHF), chronic liver disease (CLD), and older age due to perceived risk of side effects, including lactic acidosis (LA).

Recent literature highlights the rarity of metformin-associated LA and supports the cautious expansion of metformin use. In addition, in April 2016 the FDA modified its position on CKD to extend use of metformin to some patients with moderate CKD. Yet there remain uncertainties regarding the risks and benefits of metformin use in populations with CKD, CHF, CLD, and older age. For this reason, we conducted a systematic review and meta-analysis in order to determine the answers to the following key questions:

Key Questions

1. For patients with type 2 diabetes and an apparent contraindication or precaution to metformin use (eg, renal insufficiency, congestive heart failure, chronic liver disease, or older age):

a. What is the rate of lactic acidosis in patients taking metformin?

b. How does the rate of lactic acidosis in patients taking metformin compare with the rate in patients taking other hypoglycemics?

2. For patients with type 2 diabetes and an apparent contraindication or precaution to metformin use, what are the potential benefits and harms (other than lactic acidosis) of continued treatment with metformin?


See also

On April 18, 2017 the ACP Journal Club featured the article on metformin use based on this report.

Metformin Use in Patients with Historical Contraindications or Precautions (Management Brief)

Crowley MJ, Diamantidis CJ, McDuffie JR, et al. Clinical outcomes of metformin use in populations with chronic kidney disease, congestive heart failure, or chronic liver disease: a systematic review. Annals of Internal Medicine. 2017. DOI:10.7326/M16-1901