Metformin Reduces Heart Failure Readmissions
Metformin Reduces Heart Failure Readmissions Metformin Reduces Heart Failure Readmissions HealthDay News For patients with chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment, metformin use is associated with improvements in clinical outcomes, according to a review published online in the Annals of Internal Medicine. Matthew J. Crowley, MD, from the Durham Veterans Affairs Medical Center and Duke University School of Medicine in North Carolina, and colleagues synthesized data addressing outcomes of metformin use in patients with type 2 diabetes and moderate to severe CKD, CHF, or CLD with hepatic impairment. Data were included from studies that compared diabetes regimens that included metformin with those that did not, and reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest. The researchers found that metformin use correlated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic involvement on the basis of quantitative and qualitative syntheses involving 17 observational studies. In patients with CKD or CHF, metformin use correlated with fewer heart failure readmissions. "Metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment is associated with improvements in key clinical outcomes," the authors wrote. "Our findings support the recent changes in metformin labeling." Continue reading >>
Clinical Outcomes Of Metformin Use In Populations With Chronic Kidney Disease, Congestive Heart Failure, Or Chronic Liver Disease: A Systematic Review.
Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease: A Systematic Review. Family Medicine (FM)/General Practice (GP) Background: Recent changes to the U.S. Food and Drug Administration boxed warning for metformin will increase its use in persons with historical contraindications or precautions. Prescribers must understand the 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 (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment. Data Sources: MEDLINE (via PubMed) from January 1994 to September 2016, and Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015. Study Selection: English-language studies that: 1) examined adults with type 2 diabetes and CKD (with estimated glomerular filtration rate less than 60 mL/min/1.73 m2), CHF, or CLD with hepatic impairment; 2) compared diabetes regimens that included metformin with those that did not; and 3) reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest. Data Extraction: 2 reviewers abstracted data and independently rated study quality and strength of evidence. Data Synthesis: On the basis of quantitative and qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF. Limitations: Strength of evidence was low, and data on multiple outcomes of interest were sparse. Available studies Continue reading >>
Metformin May Reduce All-cause Mortality In Patients With Congestive Heart Failure
A systematic review of 17 observational studies found that metformin was associated with a reduction in all-cause mortality in patients with type 2 diabetes and chronic kidney disease, congestive heart failure or chronic liver disease with hepatic impairment. Metformin was also associated with fewer heart failure readmissions in patients with chronic kidney disease or congestive heart failure. Lead researcher Matthew J. Crowley, MD, MHS, of Duke University and the Durham Veterans Affairs Medical Center in North Carolina, and colleagues published their results online Jan. 2 in the Annals of Internal Medicine. The U.S. Department of Veterans Affairs funded the study. When the FDA approved metformin in 1994, the drug became the initial treatment option for many people with type 2 diabetes in the U.S., according to the researchers. However, the FDA required a label warning against using metformin in patients with chronic kidney disease and recommended caution for patients with congestive heart failure and chronic liver disease. The researchers noted that the FDA in 2006 removed congestive heart failure as a contraindication to metformin use, although the agency still cautions against the drug’s use in patients with acute or unstable congestive heart failure. They also noted that the FDA in April 2016 revised its warning regarding metformin use in patients with chronic kidney disease. By switching to a more inclusive criteria based on estimated glomerular filtration rate, an estimated one million additional patients with moderate chronic kidney disease are eligible to receive metformin, although the drug remains contraindicated in patients with severe chronic kidney disease. For this analysis, the researchers searched databases, the ClinicalTrials.gov website and other pub Continue reading >>
Review: Metformin Is Linked To Reduced Mortality In Type 2 Diabetes With Comorbid Ckd And Chf
ACP Diabetes Monthly | From ACP Journal Club | May 12, 2017 Review: Metformin is linked to reduced mortality in type 2 diabetes with comorbid CKD and CHF The included studies focused on metformin use in patients with chronic kidney disease (CKD), congestive heart failure (CHF), chronic liver disease (CLD), or older age. A recent review looked at studies comparing metformin, alone or with other glucose-lowering treatment, with no metformin in adults with type 2 diabetes. All studies included patients with chronic kidney disease (CKD), congestive heart failure (CHF), chronic liver disease (CLD), or older age. The review found that metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment was associated with improvements in key clinical outcomes, supporting recent changes in metformin labeling to treat more patients with these conditions. The review was published in the Feb. 7 Annals of Internal Medicine. The following commentary by Sina Jasim, MD, MPH, and Steven A Smith, MD, FACP, was published in the ACP Journal Club section of the April 18 Annals of Internal Medicine. Phenformin, a biguanide prescribed for glycemic control, was withdrawn from the market in the 1970s because of its association with often fatal lactic acidosis, especially among patients with renal disease. Metformin, also a biguanide, has been suspect ever since, without evidence that it shares the same adverse effects and despite strong recommendations for its use as first-line treatment for type 2 diabetes. The rigorous systematic review and meta-analysis by Crowley and colleagues is consistent with the literature supporting metformin use in patients with diabetes and eGFR as low as 30 mL/min/1.73 m2. Meta-analyses showed reduced all-cause mortality in patients with CHF and CKD; Continue reading >>
Metformin Associated With Reduced Mortality In Kidney Disease, Congestive Heart Failure, And Chronic Liver Disease
1. Metformin use is associated with reduced all-cause mortality in patients with chronic kidney disease, congestive heart failure, or chronic liver disease with hepatic impairment. 2. In this systemic review, fewer heart failure readmissions were observed in patients with CKD or CHF that were treated with metformin. Evidence Rating Level: 1 (Excellent) Study Rundown: Metformin is currently the suggested initial treatment for type 2 diabetes mellitus in the United States. In the past, the U.S. Food and Drug Administration (FDA did not recommend metformin for patients with chronic kidney disease (CKD), congestive heart failure (CHF), and/or chronic liver disease (CLD) with hepatic impairment. However, these recommendations were removed in 2006 due to the notion that the precautions were too restrictive. The purpose of this study, therefore, was to promote fully informed prescribing by synthesizing data addressing outcomes of metformin in these populations with historical contraindications. The authors concluded that metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment is associated with improvements in key clinical outcomes. There were several limitations to this study. First, not all outcomes of potential interest were evaluated. Additionally, strength of evidence was low and studies varied in follow-up duration. Overall, the results of this study support changes in metformin labeling to permit metformin use in additional patients with certain types of CHF, CKD, and CLD with hepatic impairment. Click to read the study, published today in the Annals of Internal Medicine Relevant Reading: Metformin in Chronic Kidney Disease: Time for a Rethink In-Depth [systematic review]: In this systematic review, articles were retrieved from MEDLINE, EMBASE, Continue reading >>
Metformin May Reduce Mortality Risk In Patients With Ckd, Cld, And Chf
Metformin May Reduce Mortality Risk in Patients with CKD, CLD, and CHF A new study published in the Annals of Internal Medicine has found that metformin was associated with lower risk of mortality in patients with type II diabetes and chronic kidney disease (CKD), congestive heart failure (CHF), and chronic liver disease (CLD) with hepatic impairment, and reduced heart failure related readmissions in patients with CKD and CHF. Researchers assessed data from 17 studies on MEDLINE from January 1994 to September 2016, Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015 that included participants with type II diabetes and CKD, CHF, or CL, were taking metformin, and included morality or major cardiovascular events in the outcomes of the study. __________________________________________________________________________________________________________________________________________ Analysis Supports Metformin as First-Line Therapy for Type 2 Diabetes __________________________________________________________________________________________________________________________________________ Their findings showed that metaformin was associated with reduced all-cause mortality in patients with CKD, CHF, and CLD with hepatic impairment. Likewise, there were fewer readmissions for patients with CKD and CHF. "Our findings support the recent changes in metformin labeling," the researchers concluded. 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 [published online January 3, 2017]. Annals of Internal Medicine. doi:10.7326/M16-1901. OA Is Significantly Impacted by Weight, Diet Patients w Continue reading >>
Continuation Of Metformin Use After A Diagnosis Of Cirrhosis Significantly Improved Survival Of Patients With Diabetes
Go to: Abstract The risks and benefits of metformin use in cirrhotic patients with diabetes are debated. Although data on a protective effect of metformin against liver cancer development have been reported, metformin is frequently discontinued once cirrhosis is diagnosed due to concerns about an increased risk of adverse effects of metformin in patients with liver impairment. This study investigated whether continuation of metformin after cirrhosis diagnosis improves survival of patients with diabetes. Diabetic patients diagnosed with cirrhosis between 2000 and 2010 who were on metformin at the time of cirrhosis diagnosis were identified (n=250). Data were retrospectively abstracted from the medical record. Survival of patients who continued versus discontinued metformin after cirrhosis diagnosis was compared using the log-rank test. The hazard ratio (HR) and 95% confidence interval (CI) were calculated using Cox Proportional Hazards analysis. 172 patients continued metformin while 78 discontinued metformin. Patients who continued metformin had a significantly longer median survival than those who discontinued metformin (11.8 vs. 5.6 years overall, P < 0.0001; 11.8 vs. 6.0 years for Child A patients, P = 0.006; and 7.7 vs. 3.5 years for Child B/C patients, P = 0.04, respectively). After adjusting for other variables, continuation of metformin remained an independent predictor of better survival with a HR of 0.43 (95%CI: 0.24-0.78, P = 0.005). No patients developed metformin-associated lactic acidosis during follow-up. Continuation of metformin after cirrhosis diagnosis reduced the risk of death by 57%. Metformin should therefore be continued in diabetic patients with cirrhosis if there is no specific contraindication. Keywords: Chronic liver disease, Non-alcoholic fatt Continue reading >>
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Metformin Appears Safe for Heart Failure, Other Diabetes Co-Morbidities DURHAM, NC While recent changes to the U.S. Food and Drug Administration boxed warning for metformin are likely to increase the common diabetes drugs use in patients with historical contraindications or precautions, prescribers are cautioned to understand the clinical outcomes of metformin use in these populations, including patients with heart failure. A review published in Annals of Internal Medicine discussed possible outcomes of metformin use in populations with type 2 diabetes and moderate to severe chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment.1 To do that, Durham, NC, VAMC and Duke University researchers analyzed studies from MEDLINE (via PubMed) from January 1994 to September 2016, and Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015. Included were English-language studies that: 1) examined adults with type 2 diabetes and CKD (with estimated glomerular filtration rate less than 60 mL/min/1.73 m2), CHF, or CLD with hepatic impairment; 2) compared diabetes regimens that included metformin with those that did not; and 3) reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest. Two reviewers abstracted data and independently rated study quality and strength of evidence, according to the report. Results indicated that, based on quantitative and qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF. Last year, the FDA announced it was requir Continue reading >>
Clinical Outcomes Of Metformin Use In Populations With (ckd), (chf), Or (cld)
Clinical outcomes of metformin use in populations with (CKD), (CHF), or (CLD) 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. Ann Intern Med. 2017 Jan 3. doi: 10.7326/M16-1901. Investigators sought to elucidate clinical outcomes of metformin use in previously contraindicated populations. In this meta-analysis, metformin use was associated with reduced all-cause mortality in patients with chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF. Though findings were supportive of the metformin labeling changes, the authors also remarked that the strength of the evidence was low. Crowley and coauthors endeavored to meta-analyze outcomes among persons having both diabetes and at least one of CKD, CHF, or CLD treated with metformin or other agents. Their search strategy incorporated 4,910 articles, of which 532 were fully reviewed and only 17 had relevant information, 6 pertaining to CKD, 11 CHF (including 3 of the CKD articles), and 3 CLD. The articles gave similar findings of 23% lower mortality among patients with moderate CKD (eGFR 30-60, although not in the one study with eGFR<30), 22% lower total and 23% lower cardiovascular mortality among patients with CHF, and generally similar if not more favorable trends among patients with CLD. Are these findings important? Yes, they help us to continue with this highly useful treatment approach for persons with diabetes having conditions previously thought of as contraindications. However, the authors emphasize in their manuscript that the strength Continue reading >>
Use Of Metformin In Chronic Kidney Disease, Congestive Heart Failure, And Chronic Liver Disease - Curr Med Issues
EVIDENCE-BASED MEDICINE: SUMMARY OF STUDY Year : 2017 | Volume : 15 | Issue : 3 | Page : 240-242 Use of metformin in chronic kidney disease, congestive heart failure, and chronic liver disease Source of Support: None, Conflict of Interest: None . Use of metformin in chronic kidney disease, congestive heart failure, and chronic liver disease. Curr Med Issues 2017;15:240-2 . Use of metformin in chronic kidney disease, congestive heart failure, and chronic liver disease. Curr Med Issues [serial online] 2017 [cited2018 Mar 28];15:240-2. Available from: Source: This is a summary of the study: Clinical Outcomes of Metformin Use in Populations with Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease: A Systematic Review. Authors: Crowley MJ, Diamantidis CJ, McDuffie JR, Cameron CB, Stanifer JW, Mock CK, et al. Ann Intern Med. 2017 Feb 7;166(3):191-200. doi: 10.7326/M16-1901. Summary prepared by Dr. Ajay Kumar Mishra, Christian Medical College, Vellore, Tamil Nadu, India. Clinical Question: Is metformin safe for use in individuals with chronic kidney disease, congestive heart failure, or chronic liver disease? Authors' conclusion: With appropriate dose optimization, the use of metformin in patients with type 2 diabetes mellitus and moderate chronic kidney disease, congestive heart failure, or chronic liver disease is associated with improvement in clinical outcomes. Case Scenario: A 65-year retired school teacher comes to a general practitioner with her concern regarding her medications. She has well-controlled diabetes, hypertension, dyslipidemia, and chronic kidney disease (CKD). Recently, she had visited another health practitioner who had advised her to stop Glyciphage (metformin) stating that this drug is contraindicated in CKD. What should be the c Continue reading >>
Metformin Reduces Mortality In Ckd, Chf, And Cld
FDA label update will increase drug use in persons with historical contraindications or precautions. From 1950 to 1995, we only had 1 class of drugs for type 2 diabetes. Then in 1994, metformin was approved. And it has become the cornerstone therapy for patients with type 2 diabetes. There was and still is a warning of possible lactic acidosis. However, because phenformin was withdrawn due to lactic acidosis in 1977, the FDA put a boxed warning on metformin stating that it should not be used in patients with chronic kidney disease (CKD), to avoid accumulation of the drug, which could possibly lead to lactic acidosis. There was also a warning concerning individuals who may accumulate lactate such as patients with congestive heart failure (CHF) and chronic liver disease (CLD). However, over the years, individuals who had CKD, CHF, or CLD were on metformin. This present study looked at these patients to see if metformin conferred any benefit relative to their chronic diseases. The researchers reviewed five observational studies with a total of 33,442 patients with moderate to severe CKD. In the metformin-treated groups, all-cause mortality was reduced by 33% (HR, 0.77). They looked at 11 observational studies with 35,410 patients with CHF. All-cause mortality was reduced by 22% (HR, 0.78) in the metformin-treated groups. In the three studies on CLD, there was a trend toward benefit with metformin; however, the numbers were small they did not reach statistical significance. This article nicely shows that there was no increased harm in using metformin in patients with CKD, CHF, or CLD; in fact, there was a significant reduction in death in CKD and CHF patients. Therefore, the new FDA label for metformin that was just updated in April 2016 seems to be a step in the right dire Continue reading >>
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The Use Of Metformin Reduces The Burden Of Chronic Liver Diseases.... Aasld Liverlearning. Wang C. Oct 20 2017; 194288
TITLE: The Use of Metformin Reduces the Burden Of Chronic Liver Diseases in Hispanic Veterans with Type 2 Diabetes SPONSORSHIP - THIS STUDY WAS SPONSORED BY:(IF THIS ABSTRACT WAS NOT SPONSORED PLEASE INDICATE): This study was partially supported by R21CA161180. Background: Chronic liver disease (CLD) disproportionally affects certain race/ethnic groups. Hispanics are at higher risk for developing nonalcoholic fatty liver disease. Pharmacological interventions are yet to be identified to reduce this disparity. Metformin is the most commonly prescribed oral medication for treating type 2 diabetes (T2D). This study examined if long-term use of metformin reduces CLD and the associated disparity. Methods: A historical cohort (n=71,647) was derived from the nationwide VA electronic medical records during 2003-2006. Inclusion criteria: male patients with T2D; aged 40-89 years; without cancer or liver diseases prior to 2003; without prescription for insulin or thiazolidinediones. Patients included were either metformin users (use 180 days) or none users. The outcome was the diagnosis of CLD based on ICD9 codes. Analysis: Logistic regression analysis, adjusting for age, HbA1c, LDL, BMI, comorbidities, beta-blocker and statin use, and the propensity scores of metformin use and race/ethnicity status, to estimate the odds ratio (OR) of CLD associated with metformin use and race/ethnicity. Results: Patient characteristics by race/ethnicity and metformin use are shown in the Table. Among patients without metformin use, the adjusted OR of CLD diagnosis for African-American (AA) vs. non-Hispanic white (NHW) was 0.58 (95% CI: 0.48-0.70), and for Hispanics vs. NHW was 2.10 (1.61-2.74), indicating higher burden of CLD in Hispanics, and reduced burden in AA. The adjusted OR of CLD for met Continue reading >>
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Consensus Statement On Dose Modifications Of Antidiabetic Agents In Patients With Hepatic Impairment Gangopadhyay Kk, Singh P - Indian J Endocr Metab
The liver has an important role in carbohydrate metabolism. It is responsible for the balance of blood glucose levels by means of neoglucogenesis and glycogenolysis. [1] The metabolic homeostasis of glucose is impaired in the presence of chronic liver disease (CLD) resulting in insulin resistance (IR), glucose intolerance, and diabetes. [1] , [2] , [3] According to a report, the prevalence of diabetes mellitus (DM) in patients with CLD is reportedly 18%–71%. [4] In another report, glucose intolerance is seen in up to 80% of patients with CLD and diabetes in 30%–60%. [5] Moreover, in case of liver cirrhosis, glucose intolerance and diabetes is present in approximately 96% of the patients. [6] Hence, diabetes and CLD often coexist and existing evidence suggests that CLD increases complications and premature mortality in patients with diabetes. [7] Association between diabetes and CLD is given in [Figure 1] . Figure 1: Relationship between diabetes and chronic liver disease. HCV: Hepatitis C Virus; HCC: Hepatocellular Carcinoma; NAFLD: Nonalcoholic Fatty Liver Disease; DM: Diabetes Mellitus; T2DM: Type 2 Diabetes Mellitus In contrast to the involvement of liver disease in causing diabetes, diabetes has also been proposed as a risk factor for both CLD and hepatocellular carcinoma (HCC). In fact, diabetes, by most estimates, is now the most common cause of liver disease cryptogenic cirrhosis and has become the third leading indication for liver transplantation in the United States. DM has been commonly associated with nonalcoholic fatty liver disease (NAFLD), including its most severe form, nonalcoholic steatohepatitis (NASH). NASH is a chronic necroinflammatory condition that can lead to liver fibrosis, cirrhosis, and subsequently to HCC. [8] In addition, there is an u Continue reading >>
Metformin Benefits Patients Historically Kept From Using It
Metformin benefits patients historically kept from using it Metformin benefits patients historically kept from using it Metformin has enjoyed a long run as the first-line standard of care against type 2 diabetes—except in patients who also have chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD). These contraindications have loosened somewhat, however, as evidence has mounted against the basis for them. Metformin has enjoyed a long run as the first-line standard of care against type 2 diabetesexcept in patients who also have chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD). These contraindications have loosened somewhat, however, as evidence has mounted against the basis for them. Earlier concerns about lactic acidosis in patients with moderate CKD, CHF, or CLD have been largely eliminated; and a recent systematic review found that metformin can help diabetics previously advised against its use. The Department of Veterans Affairs-funded analysis included 17 observational studies. The findings pointed to a 22% lower risk of all-cause death in study participants taking metformin, compared with those not taking it. The drug also curbed CHF admissions in patients with moderate CKD and CHF while reducing hypoglycemia risk in patients with CKD. "The idea that a low-cost therapy like metformin could provide some of the same mortality benefits that newer drugs seem to would be huge," suggested lead author Matthew J. Crowley, MD, from Durham Veteran's Affairs Medical Center and Duke University. "It would be really valuable for patients with diabetes all across the country and the world." The results are published in the Annals of Internal Medicine. Continue reading >>
Metformin Linked To Decreased Mortality In Ckd, Chf, And Liver Disease
Metformin is associated with lower all-cause mortality in patients with moderate chronic kidney disease (CKD), congestive heart failure (CHF) and chronic liver disease (CLD), according to a study published in the February issue of the Annals of Internal Medicine.1 “Although data were limited, we found no evidence to suggest that metformin's benefits do not extend to patients with moderate CKD, CHF, or CLD with impaired hepatic function. Together with reports regarding the safety of metformin with respect to lactic acidosis, our findings support the FDA's recent actions,” wrote first author Matthew Crowley, MD, of Durham Veterans Affairs Medical Center (Durham, NC) and Duke University, and colleagues.2 When metformin was first approved in 1994, it was contraindicated in patients with CKD and CLD, due to concerns over lactic acidosis. Several years later, the US Food and Drug Administration (FDA) also advised against its use in CHF. These warnings were motivated, in part, by concerns for lactic acidosis with use of phenformin, a related drug that was pulled from the market in 1977.1,2 Over the years, the FDA has relaxed some of the restrictions over metformin’s use. In 2006, the agency removed CHF as a contraindication for the drug, though still cautioned about its use in acute or unstable CHD.2 In April 2016, the FDA changed metformin’s boxed warning, expanding its use to patients with mild kidney impairment and some patients with moderate renal impairment.3 Collectively, these changes will likely increase metformin use in patients who would have had contraindications in the past. Effective in more patients? To evaluate whether metformin use improves outcomes in an expanded population of patients, researchers searched Medline from January 1994 to September 2016, Continue reading >>
