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Is Metformin Contraindicated In Congestive Heart Failure?

Metformin Contraindications

Metformin Contraindications

The biguanide metformin (dimethylbiguanide) was initially introduced for use in the treatment of type 2 diabetes mellitus in the late 1950s. Today this drug is considered to be the first-choice agent and the “gold standard” for most people with type 2 diabetes. It has been estimated that the annual number of people receiving prescriptions for metformin worldwide is more than 120 million. The efficacy and benefits of metformin treatment in type 2 diabetes have been confirmed by large-scale studies and recognized by many consensus statements. Still, a large list of contraindications may increase the incidence of serious adverse effects, which precludes many patients from taking metformin. Intolerance and contraindications to metformin Three particular contraindications to the use of metformin have been suggested. They include renal impairment with elevated serum creatine levels (i.e. more than 136 mmol/l in men and 124 mmol/l in women) or abnormal creatinine clearance, congestive heart failure requiring pharmacologic treatment and advanced age (more than 80 years of age). Renal impairment represents a contraindication to metformin usage due to the increased risk of lactic acidosis (a form of metabolic acidosis due to the inadequate clearance of lactic acid from the blood). Although lactic acidosis linked to metformin is a rare condition, with an estimated prevalence of one to five cases per 100 000 population, it has a reported mortality of 30-50%. However, recent studies have suggested that metformin can be used safely, unless the estimated glomerulal filtration rate (the volume of fluid that is filtered from the capillaries of the glomeruli into the kidney tubules per unit time) falls below 30 ml/min, with a dose reduction advised at 45 ml/min. Congestive heart fail Continue reading >>

Effects Of Metformin In Heart Failure Patients

Effects Of Metformin In Heart Failure Patients

Hypothesis: In patients, who have diabetes type 2, are treated with metformin, and are admitted for HF, leads to reduced insulin requirements, as measured in units of insulin, with no negative impact on patient safety. This is a single center, prospective trial. Subjects will be randomized to initiate metformin (starting dose 500mg orally once daily up to a maximum dose of 2,500mg daily) OR be placed on insulin products for management of their type 2 diabetes mellitus. Because of the state of insulin resistance in heart failure (HF), metformin, with its ability to sensitize tissues to insulin, seems to be an ideal agent for managing type 2 diabetes mellitus (DM) in HF. It reduces the concentration of glucose in blood by enhancing insulin sensitivity, inducing greater peripheral uptake of glucose, and decreasing hepatic glucose output. However, according to the package insert, it is contraindicated in all patients with HF requiring pharmacologic treatment because of increased risk of lactic acidosis. The FDA has now de-escalated this contraindication to a warning as the evidence is lacking regarding an increased risk of lactic acidosis in patients with type 2 DM and HF who take metformin. Hypothesis: In patients, who have diabetes type 2, are treated with metformin, and are admitted for HF, metformin leads to reduced insulin requirements, as measured in units of insulin, with no negative impact on patient safety. Primary Objective: To test the hypothesis that continuing a patient's home metformin for diabetes management while admitted to UK hospital will result in decreased utilization of insulin as denoted by total units given. Secondary Objectives: To test the hypothesis that administering metformin in HF patients admitted to UK Hospital: Results in similar glycemic co Continue reading >>

Metformin And Heart Failure: Never Say Never Again

Metformin And Heart Failure: Never Say Never Again

Metformin and heart failure: never say never again Metformin represents the cornerstone of treatment for type 2 diabetes mellitus. Traditionally, heart failure (HF) was considered a contraindication to its use. However, more recent evidence has shown that this should no longer be the case. Indeed, studies have demonstrated that metformin may even reduce the risk of incident HF and mortality in diabetic patients, while improving up to 2-year survival rates in those with HF. In addition, it appears to exert cardioprotective actions. Although longer follow-up data and more explicit information about the situation in patients with very advanced HF are needed, the cardiac safety of metformin has profound clinical implications and may be anticipated to further encourage its widespread use. Keywords: contraindications , diabetes mellitus , heart failure , metformin , oral hypoglycaemic agents Metformin has long been established as the mainstay of treatment for type 2 diabetes mellitus (T2DM) [1,2] Nathan DM, Buse JB, Davidson MB, Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009;32:193-203 Papanas N, Maltezos E, Mikhailidis DP. Metformin: diamonds are forever. Expert Opin Pharmacother 2009;10:2395-7. Not only does it reduce hyperglycaemia but it is not associated with unwanted hypoglycaemia (unless used along with insulin or excessive exercise), and it has favourable actions on body weight and serum lipids [3] Bolen S, Feldman L, Vassy J, Systematic review: comparative effectiveness and safety of oral medications for type 2 diabetes mellitus. Ann Intern Med 2007;147:386-9 Continue reading >>

Comparative Safety And Effectiveness Of Metformin In Patients With Diabetes Mellitus And Heart Failure

Comparative Safety And Effectiveness Of Metformin In Patients With Diabetes Mellitus And Heart Failure

Comparative Safety and Effectiveness of Metformin in Patients With Diabetes Mellitus and Heart Failure Systematic Review of Observational Studies Involving 34 000 Patients MD, MScFrom the Department of Public Health Sciences, School of Public Health (D.T.E., D.L.W., R.T.T., J.A.J.), Department of Medicine, Faculty of Medicine and Dentistry (S.R.M., R.T.T., F.A.M.), ACHORD, Li Ka Shing Center, University of Alberta, Edmonton, Alberta, Canada (L.T.); and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada (S.E.V.). From the Department of Public Health Sciences, School of Public Health (D.T.E., D.L.W., R.T.T., J.A.J.), Department of Medicine, Faculty of Medicine and Dentistry (S.R.M., R.T.T., F.A.M.), ACHORD, Li Ka Shing Center, University of Alberta, Edmonton, Alberta, Canada (L.T.); and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada (S.E.V.). From the Department of Public Health Sciences, School of Public Health (D.T.E., D.L.W., R.T.T., J.A.J.), Department of Medicine, Faculty of Medicine and Dentistry (S.R.M., R.T.T., F.A.M.), ACHORD, Li Ka Shing Center, University of Alberta, Edmonton, Alberta, Canada (L.T.); and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada (S.E.V.). From the Department of Public Health Sciences, School of Public Health (D.T.E., D.L.W., R.T.T., J.A.J.), Department of Medicine, Faculty of Medicine and Dentistry (S.R.M., R.T.T., F.A.M.), ACHORD, Li Ka Shing Center, University of Alberta, Edmonton, Alberta, Canada (L.T.); and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada (S.E.V.). From the Department of Public Health Sciences, School of Public Health (D.T.E., D.L.W., R.T.T., J.A.J.), Department of Medicine, Faculty of Continue reading >>

Metformin In Diabetic Patients With Heart Failure: Safe And Effective?

Metformin In Diabetic Patients With Heart Failure: Safe And Effective?

Metformin in Diabetic Patients with Heart Failure: Safe and Effective? The University of Texas Medical School at Houston, Division of Cardiovascular Medicine Correspondence to: Heinrich Taegtmeyer, MD, DPhil, 6431 Fannin St, MSB 1.246, Tel: 713-500-6569, Fax: 713-500-0637, [email protected] Ijeoma Ananaba Ekeruo, MD, 6431 Fannin St, MSB 1.246, Tel: 713-500-6569, Fax: 713-500-0637, [email protected] Amirreza Solhpour, MD, 6431 Fannin St, MSB 1.246, Tel: 713-500-6569, Fax: 713-500-0637, [email protected] See other articles in PMC that cite the published article. Management of diabetic patients with heart failure is a complex endeavor. The initial reluctance to use metformin in these patients has given way to a broader acceptance after clinical trials and meta-analyses have revealed that some of the insulin-sensitizing agents lead to adverse cardiovascular events. We have proposed that an increase of substrate uptake by the insulin-resistant heart is detrimental because the heart is already flooded with fuel. In light of this evidence, metformin offers a unique safety profile in the patient with diabetes and heart failure. Our article expands on the use of metformin in patients with heart failure. We propose that the drug targets both the source as well as the destination (in this case the heart) of excess fuel. We consider treatment of diabetic heart failure patients with metformin both safe and effective. Keywords: Type 2 Diabetes Mellitus, Heart Failure, Anti-diabetic Drugs Of the estimated 25.8 million people with the diagnosis of type 2 diabetes in the United States, about 30% will develop heart failure( 1 ), contributing to the exorbitant cost of diabetes. For example, in 2012 alone, the cost of diagnosed diabetes was $245 billion in total Continue reading >>

Metformin Use In Populations With Ckd, Chf, Or Cld | Annals Of Internal Medicine | American College Of Physicians

Metformin Use In Populations With Ckd, Chf, Or Cld | Annals Of Internal Medicine | American College Of Physicians

Author, Article, and Disclosure Information This article was published at Annals.org on 3 January 2017. From Durham Veterans Affairs Medical Center and Duke University School of Medicine, Durham, North Carolina. Disclaimer: The views expressed in this article do not necessarily reflect the position of the Department of Veterans Affairs or Duke University. Acknowledgment: The authors thank David DAlessio, MD, for his critical review of this manuscript and Liz Wing, MA, for her editorial assistance. Grant Support: This project was supported by the VHA Evidence-based Synthesis Program (project 09-009). Dr. Crowley is supported by a Career Development Award from VHA Health Services Research and Development (CDA 13-261). Dr. Diamantidis is supported by a Mentored Patient-Oriented Research Career Development Award from the National Institute of Diabetes and Digestive and Kidney Diseases (K23-DK099385). Disclosures: Drs. Crowley, Kosinski, and Williams report grants from the Veterans Administration Quality Enhancement Research Initiative during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1901 . Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that sh Continue reading >>

Metformin Linked To Decreased Mortality In Ckd, Chf, And Liver Disease

Metformin Linked To Decreased Mortality In Ckd, Chf, And Liver Disease

Metformin Linked to Decreased Mortality in CKD, CHF, and Liver Disease Practical Cardiology , Practical Cardiology , Cardiovascular Disease , Heart Failure 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 metformins 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 metformins 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. To evaluate whether metformin use improv Continue reading >>

Metformin And Heart Failure: Never Say Never Again

Metformin And Heart Failure: Never Say Never Again

Metformin represents the cornerstone of treatment for type 2 diabetes mellitus. Traditionally, heart failure (HF) was considered a contraindication to its use. However, more recent evidence has shown that this should no longer be the case. Indeed, studies have demonstrated that metformin may even reduce the risk of incident HF and mortality in diabetic patients, while improving up to 2-year survival rates in those with HF. In addition, it appears to exert cardioprotective actions. Although longer follow-up data and more explicit information about the situation in patients with very advanced HF are needed, the cardiac safety of metformin has profound clinical implications and may be anticipated to further encourage its widespread use. 1. Introduction Metformin has long been established as the mainstay of treatment for type 2 diabetes mellitus (T2DM) [1,2] Nathan DM, Buse JB, Davidson MB, Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2009;32:193-203 Papanas N, Maltezos E, Mikhailidis DP. Metformin: diamonds are forever. Expert Opin Pharmacother 2009;10:2395-7. Not only does it reduce hyperglycaemia but it is not associated with unwanted hypoglycaemia (unless used along with insulin or excessive exercise), and it has favourable actions on body weight and serum lipids [3]. More importantly, based on an observational study of participants in a large randomised controlled trial (RCT), it confers long-term protection from all T2DM-related endpoints, myocardial infarction and death from any cause [4]. Traditionally, the use of metformin has been subject to contraindications Continue reading >>

(pdf) Metformin In Heart Failure Patients

(pdf) Metformin In Heart Failure Patients

Diabetes causes cardiomyopathy and increases the risk of heart failure independent of hypertension and coronary heart disease. This condition called "Diabetic Cardiomyopathy" (DCM) is becoming a well- known clinical entity. Recently, there has been substantial research exploring its molecular mechanisms, structural and functional changes, and possible development of therapeutic approaches for the prevention and treatment of DCM. This review summarizes the recent advancements to better understand fundamental molecular abnormalities that promote this cardiomyopathy and novel therapies for future research. Additionally, different diagnostic modalities, up to date screening tests to guide clinicians with early diagnosis and available current treatment options has been outlined. BackgroundMetformin is the most widely used oral antihyperglycemic agent for patients with type 2 diabetes mellitus (T2DM). Despite the possible benefits of metformin on diabetes mellitus (DM) and heart failure (HF), acute or unstable HF remains a precaution for its use.ObjectiveThe aim of the present prospective randomized controlled trial was to assess whether metformin treatment has beneficial effects on patients with T2DM with hypertension without overt HF.MethodsA total of 164 patients (92 males, 72 females; median age 66 years) were included in this study. Patients with T2DM with a history of hypertension were randomized 1:1 to treatment for 1 year with either metformin (metformin-treated group) or other hypoglycemic agents (control group). The primary endpoints were changes in brain natriuretic peptide (BNP) levels, left ventricular (LV) mass index, and indicators of LV diastolic function. We also evaluated changes in both clinical findings and blood laboratory examination data.ResultsWe obse Continue reading >>

Use Of Metformin In Chronic Kidney Disease, Congestive Heart Failure, And Chronic Liver Disease - Curr Med Issues

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 And Thiazolidinedione Use In Medicare Patients With Heart Failure

Metformin And Thiazolidinedione Use In Medicare Patients With Heart Failure

Metformin and Thiazolidinedione Use in Medicare Patients With Heart Failure ContextAccording to package inserts, metformin is contraindicated in diabeticpatients receiving drug treatment for heart failure therapy, and thiazolidinedionesare not recommended in diabetic patients with symptoms of advanced heart failure.Little is known about patterns of use of these antihyperglycemic drugs indiabetic patients with heart failure. ObjectiveTo determine the proportions of patients hospitalized with heart failureand concomitant diabetes treated with metformin or thiazolidinediones. DesignSerial cross-sectional measurements using data from retrospective medicalrecord abstraction. SettingNongovernmental acute care hospitals in the United States. PatientsTwo nationally representative samples of Medicare beneficiaries hospitalizedwith the primary diagnosis of heart failure and concomitant diabetes betweenApril 1998 and March 1999 and between July 2000 and June 2001. Main Outcome MeasuresThe prescription of either metformin or a thiazolidinedione at hospitaldischarge. ResultsIn the 1998-1999 sample (n = 12505), 7.1% of patients were dischargedwith a prescription for metformin, 7.2% with a prescription for a thiazolidinedione,and 13.5% with a prescription for either drug. In the 2000-2001 sample (n= 13158), metformin use increased to 11.2%, thiazolidinedione use to16.1%, and use of either drug to 24.4% (P<.001for all comparisons). Similar increases were seen among patients of all agegroups, all races, and both sexes. ConclusionsThe use of metformin and thiazolidinediones is common and has increasedrapidly in Medicare beneficiaries with diabetes and heart failure in directcontrast with explicit warnings against this practice by the Food and DrugAdministration. Further studies to estab Continue reading >>

(pdf) Metformin, Heart Failure, And Lactic Acidosis: Is Metformin Absolutely Contraindicated?

(pdf) Metformin, Heart Failure, And Lactic Acidosis: Is Metformin Absolutely Contraindicated?

contraindications to metformin use. In this article we review the evidence for the use of metformin in the presence of stated contraindications and especially We searched Medline with the following terms: metformin, phenformin, biguanides, biguanide, lactic acidosis, lactic acid, heart failure, cardiac failure, con- gestive cardiac failure, left ventricular impairment, metformin contraindications, renal impairment, renal failure, diabetes, type 2 diabetes, non-insulin depend- ent diabetes, and combinations of these terms. In addition, we consulted the Cochrane systematic Metformin and risk of lactic acidosis: what evidence? The perceived risk of developing lactic acidosis with metformin is high, particularly in the United States. An increasing body of evidence challenges the so These differences might explain the lower incidence of lactic acidosis with stringent contraindications applied after the experi- ence with phenformin. However, despite increased disregard of contraindications to metformin, as dis- cussed below, the incidence of lactic acidosis has Metformin and phenformin have different phar- macological characteristics that could explain the much lower incidence of lactic acidosis associated with metformin. Table 1 summarises some of these Most case reports of lactic acidosis in people taking metformin have failed to provide adequate infor- mation to permit assessment of causation, includ- of published case reports, Stades et al showed that plasma concentrations of metformin were not related increased concentrations of neither lactic acid nor metformin were associated with increased mortal- In contrast, acute cardiovascular events, liver cirrhosis, and sepsis were all associated with an of the cases in this review had at least one risk fac- tor (renal failure, Continue reading >>

Metformin May Reduce All-cause Mortality In Patients With Congestive Heart Failure

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 >>

Metformin Associated With Reduced Mortality In Kidney Disease, Congestive Heart Failure, And Chronic Liver Disease

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 Revisited: A Critical Review Of The Benefitrisk Balance In At-risk Patients With Type 2 Diabetes - Em|consulte

Metformin Revisited: A Critical Review Of The Benefitrisk Balance In At-risk Patients With Type 2 Diabetes - Em|consulte

Received:8February2013; accepted:12February2013 Metformin revisited: A critical review of the benefitrisk balance in at-risk patients with type 2 diabetes La metformine revisite: une revue critique de la balance bnfice/risque chez les patients diabtiques de type 2dits risque Division of Diabetes, Nutrition and Metabolic Disorders and Division of Clinical Pharmacology, Department of Medicine, CHU Sart-Tilman (B35), University of Lige, 4000 Lige, Belgium Corresponding author. Tel.: +32 4 3667238; fax: +32 4 3667068. Metformin is unanimously considered a first-line glucose-lowering agent. Theoretically, however, it cannot be prescribed in a large proportion of patients with type 2 diabetes because of numerous contraindications that could lead to an increased risk of lactic acidosis. Various observational data from real-life have shown that many diabetic patients considered to be at risk still receive metformin and often without appropriate dose adjustment, yet apparently with no harm done and particularly no increased risk of lactic acidosis. More interestingly, recent data have suggested that type 2 diabetes patients considered at risk because of the presence of traditional contraindications may still derive benefit from metformin therapy with reductions in morbidity and mortality compared with other glucose-lowering agents, especially sulphonylureas. The present review analyzes the benefitrisk balance of metformin therapy in special populations, namely, patients with stable coronary artery disease, acute coronary syndrome or myocardial infarction, congestive heart failure, renal impairment or chronic kidney disease, hepatic dysfunction and chronic respiratory insufficiency, all conditions that could in theory increase the risk of lactic acidosis. Special attention is al Continue reading >>

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