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Metformin Contraindications

Metformin Use In Renal Impairment Extended

Metformin Use In Renal Impairment Extended

For patients with a creatinine clearance of 45–59ml/min or an eGFR of 45–59ml/min/1.73m2, the initial dose of metformin is 500mg or 850mg once daily in the morning with food. The maximum daily dose is 1g in two divided doses with monitoring of renal function every 3–6 months. This change to the prescribing information reflects the advice given in the NICE clinical guideline on the management of type II diabetes, namely that metformin can be used with caution in patients with renal impairment but the dose should be reviewed if the patient's eGFR drops below 45ml/min/1.73m2 and treatment discontinued if the eGFR drops below 30ml/min/1.73m2. The metformin drug entry in MIMS has been updated to reflect the current Glucophage SPCs. The MIMS drug listings for products containing metformin in combination with other drugs (eg, dipeptidyl peptidase 4 inhibitors, SGLT2 inhibitors, pioglitazone) will be updated when the updated SPCs become available. Prescribers should refer to the product SPCs to check if a combination product is suitable for an individual patient with renal impairment. Follow MIMS on Twitter Continue reading >>

Lactic Acidosis As A Serious Perioperative Complication Of Antidiabetic Biguanide Medication With Metformin

Lactic Acidosis As A Serious Perioperative Complication Of Antidiabetic Biguanide Medication With Metformin

Biguanides have been established in the therapy of non-insulin-dependent diabetes mellitus for decades. However, after the introduction of sulfonylureas, biguanides were nearly eliminated from the market, largely because of the risk of severe lactic acidosis. [1–4 ] In the Unites States, use of biguanides was stopped in 1976 for this reason. [3 ] In 1995, the biguanide metformin was approved for the US market. [2,5 ] The advantage is that biguanides reduce hyperglycemia with only a very low risk for hypoglycemia. [2,6 ] In addition, they have a positive effect on blood lipid concentration and lead to a mild weight reduction in obese patients. [5,7 ] Again, however, the most important risk is the development of severe lactic acidosis. [1,4 ] Little information is available in the current anesthesia literature about the perioperative management of patients who receive biguanides. The following report describes the clinical course of a patient receiving metformin therapy who developed severe lactic acidosis after minor surgery. A 66-yr-old man was admitted for surgical repair of an abdominal wall hernia. He had a history of hypertension, non-insulin-dependent diabetes mellitus, peripheral vascular disease, obesity, and a previous pulmonary embolism. On admission, the patient was in good health. His arterial blood pressure, blood glucose, creatinine, and blood urea nitrogen levels were within normal limits. His medications were nifedipine, isosorbitmononitrate, metformin, and phenprocoumon (coumarin). After the coumarin was replaced by intravenous heparin, the patient had an uncomplicated hernia repair, which was performed with the patient during fentanyl/N2O/isoflurane balanced anesthesia. His immediate postoperative course was uncomplicated, and he was discharged from t Continue reading >>

Metformin 500mg Master Contraindications For Metformin Use In Horses Sigridjuselius.fi

Metformin 500mg Master Contraindications For Metformin Use In Horses Sigridjuselius.fi

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They Are Available As Monotherapy Or Combination Therapies, With The Latter Involving Two (or, Less Commonly, Three) Antidiabetic Drugs And/or

They Are Available As Monotherapy Or Combination Therapies, With The Latter Involving Two (or, Less Commonly, Three) Antidiabetic Drugs And/or

Antidiabetic drugs (with the exception of insulin) are all pharmacological agents that have been approved for hypoglycemic treatment in type 2 diabetes mellitus (DM). If lifestyle modifications (weight loss, dietary modification, and exercise) do not sufficiently reduce A1C levels (target level: ∼ 7%), pharmacological treatment with antidiabetic drugs should be initiated. These drugs may be classified according to their mechanism of action as insulinotropic or non-insulinotropic. They are available as monotherapy or combination therapies, with the latter involving two (or, less commonly, three) antidiabetic drugs and/or insulin. The exact treatment algorithms are reviewed in the treatment section of diabetes mellitus. The drug of choice for all type 2 diabetic patients is metformin. This drug has beneficial effects on glucose metabolism and promotes weight loss or at least weight stabilization. In addition, numerous studies have demonstrated that metformin can reduce mortality and the risk of complications. If metformin is contraindicated, not tolerated, or does not sufficiently control blood glucose levels, another class of antidiabetic drug may be administered. Most antidiabetic drugs are not recommended or should be used with caution in patients with moderate or severe renal failure or other significant comorbidities. Oral antidiabetic drugs are not recommended during pregnancy or breastfeeding. 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 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 >>

In Brief: New Recommendations For Use Of Metformin In Renal Impairment

In Brief: New Recommendations For Use Of Metformin In Renal Impairment

The FDA has required labeling changes that replace serum creatinine (SCr) with estimated glomerular filtration rate (eGFR) as the parameter used to determine the appropriateness of treatment with the biguanide metformin (Glucophage, and others) in patients with renal impairment. These changes will allow more patients with mild to moderate renal impairment to receive metformin, which is generally the first drug prescribed for treatment of type 2 diabetes. Metformin was previously contraindicated in women with a SCr level ≥1.4 mg/dL and in men with a SCr level ≥1.5 mg/dL, but use of SCr as a surrogate indicator tends to underestimate renal function in certain populations (e.g., younger patients, men, black patients, patients with greater muscle mass). The calculation of eGFR takes into account age, race, and sex, as well as SCr level, providing a more accurate assessment of kidney function. A literature review summarized in an FDA Drug Safety Communication concluded that, based on eGFR, metformin is safe to use in patients with mild renal impairment and in some patients with moderate renal impairment.1 The eGFR should be calculated before patients begin treatment with metformin and at least annually thereafter. Metformin is now contraindicated in patients with an eGFR <30 mL/min/1.73 m2, and starting treatment with the drug in patients with an eGFR between 30 and 45 mL/min/1.73 m2 is not recommended. If the eGFR falls below 45 mL/min/1.73 m2 in a patient already taking metformin, the benefits and risks of continuing treatment should be assessed. Metformin should be not be administered for 48 hours after an iodinated contrast imaging procedure in patients with an eGFR <60 mL/min/1.73 m2 or a history of liver disease, alcoholism, or heart failure, or in those receiving Continue reading >>

Glucophage

Glucophage

GLUCOPHAGE® (metformin hydrochloride) Tablets GLUCOPHAGE® XR (metformin hydrochloride) Extended-Release Tablets DESCRIPTION GLUCOPHAGE® (metformin hydrochloride) Tablets and GLUCOPHAGE® XR (metformin hydrochloride) Extended-Release Tablets are oral antihyperglycemic drugs used in the management of type 2 diabetes. Metformin hydrochloride (N,N-dimethylimidodicarbonimidic diamide hydrochloride) is not chemically or pharmacologically related to any other classes of oral antihyperglycemic agents. The structural formula is as shown: Metformin hydrochloride is a white to off-white crystalline compound with a molecular formula of C4H11N5 HCl and a molecular weight of 165.63. Metformin hydrochloride is freely soluble in water and is practically insoluble in acetone, ether, and chloroform. The pK of metformin is 12.4. The pH of a 1% aqueous solution of metformin hydrochloride is 6.68. GLUCOPHAGE tablets contain 500 mg, 850 mg, or 1000 mg of metformin hydrochloride. Each tablet contains the inactive ingredients povidone and magnesium stearate. In addition, the coating for the 500 mg and 850 mg tablets contains hypromellose and the coating for the 1000 mg tablet contains hypromellose and polyethylene glycol. GLUCOPHAGE XR contains 500 mg or 750 mg of metformin hydrochloride as the active ingredient. GLUCOPHAGE XR 500 mg tablets contain the inactive ingredients sodium carboxymethyl cellulose, hypromellose, microcrystalline cellulose, and magnesium stearate. GLUCOPHAGE XR 750 mg tablets contain the inactive ingredients sodium carboxymethyl cellulose, hypromellose, and magnesium stearate. System Components And Performance GLUCOPHAGE XR comprises a dual hydrophilic polymer matrix system. Metformin hydrochloride is combined with a drug release controlling polymer to form an “inne Continue reading >>

Tips From Other Journals - American Family Physician

Tips From Other Journals - American Family Physician

Am Fam Physician.1998Feb1;57(3):536-537. In 1995, biguanide metformin was approved by the U.S. Food and Drug Administration for use in the treatment of type 2 diabetes. Use of biguanide phenformin in the 1970s led to its subsequent withdrawal from the market in many countries because of a high incidence of lactic acidosis in patients with renal impairment, hepatic dysfunction or cardiac disease. Sulkin and associates studied the prevalence of conditions currently regarded as contraindications or cautions to the use of metformin in patients receiving this agent. The authors identified the following potential contraindications or cautions to metformin therapy: (1) renal impairment, defined as a plasma creatinine level greater than 1.4 mg per dL (120 mol per L) or dipstick-positive proteinuria, (2) cardiac failure, (3) chronic hepatic dysfunction, (4) significant chronic pulmonary disease, (5) coronary artery disease, (6) peripheral vascular disease, and (7) miscellaneous conditions (intercurrent illnesses, acute trauma or major surgical procedures, and metastatic malignancy). The authors reviewed the medical records of 89 patients receiving metformin to identify the prevalence of potential contraindications to the use of the drug. These patients were seen at a university hospital diabetes clinic in the United Kingdom. The authors found that over one half of the patients had conditions regarded as cautions or contraindications to the use of metformin, eight of the patients had two conditions, five patients had three conditions and one patient had four conditions. The most common conditions were peripheral vascular disease (22 patients), ischemic heart disease (20 patients) and proteinuria (14 patients). Two of the patients had a significant degree of renal impairment. The Continue reading >>

Metformin - Oral, Glucophage

Metformin - Oral, Glucophage

are allergic to dapagliflozin or any of the ingredients in FARXIGA. Symptoms of a serious allergic reaction may include skin rash, raised red patches on your skin (hives), swelling of the face, lips, tongue, and throat that may cause difficulty in breathing or swallowing. If you have any of these symptoms, stop taking FARXIGA and contact your healthcare provider or go to the nearest hospital emergency room right away have severe kidney problems or are on dialysis. Your healthcare provider should do blood tests to check how well your kidneys are working before and during your treatment with FARXIGA Dehydration (the loss of body water and salt), which may cause you to feel dizzy, faint, lightheaded, or weak, especially when you stand up (orthostatic hypotension). You may be at a higher risk of dehydration if you have low blood pressure; take medicines to lower your blood pressure, including water pills (diuretics); are 65 years of age or older; are on a low salt diet, or have kidney problems Ketoacidosis occurred in people with type 1 and type 2 diabetes during treatment with FARXIGA. Ketoacidosis is a serious condition which may require hospitalization and may lead to death. Symptoms may include nausea, tiredness, vomiting, trouble breathing, and abdominal pain. If you get any of these symptoms, stop taking FARXIGA and call your healthcare provider right away. If possible, check for ketones in your urine or blood, even if your blood sugar is less than 250 mg/dL Kidney problems. Sudden kidney injury occurred in people taking FARXIGA. Talk to your doctor right away if you reduce the amount you eat or drink, or if you lose liquids; for example, from vomiting, diarrhea, or excessive heat exposure Serious urinary tract infections (UTI), some that lead to hospitalization, occu Continue reading >>

Why Is Metformin Contraindicated In Chronic Kidney Disease?

Why Is Metformin Contraindicated In Chronic Kidney Disease?

To the Editor: In their article about the care of patients with advanced chronic kidney disease, Sakhuja et al1 mentioned that metformin is contraindicated in chronic kidney disease. Metformin is a good and useful drug. Not only is it one of the cheapest antidiabetic medications, it is the only one shown to reduce cardiovascular mortality rates in type 2 diabetes mellitus. Although metformin is thought to increase the risk of lactic acidosis, a Cochrane review2 found that the incidence of lactic acidosis was only 4.3 cases per 100,000 patient-years in patients taking metformin, compared with 5.4 cases per 100,000 patient-years in patients not taking metformin. Furthermore, in a large registry of patients with type 2 diabetes and atherothrombosis,3 the rate of all-cause mortality was 24% lower in metformin users than in nonusers, and in those who had moderate renal impairment (creatinine clearance 30–59 mL/min/1.73 m2) the difference was 36%.3 A trial by Rachmani et al4 raised questions about the standard contraindications to metformin. The authors reviewed 393 patients who had at least one contraindication to metformin but who were receiving it anyway. Their serum creatinine levels ranged from 1.5 to 2.5 mg/dL. There were no cases of lactic acidosis reported. The patients were then randomized either to continue taking metformin or to stop taking it. At 2 years, the group that had stopped taking it had gained more weight, and their glycemic control was worse. In the Cochrane analysis,2 although individual creatinine levels were not available, 53% of the studies reviewed did not exclude patients with serum creatinine levels higher than 1.5 mg/dL. This equated to 37,360 patient-years of metformin use in studies that included patients with chronic kidney disease, and did Continue reading >>

Safe Prescribing Of Metformin In Diabetes

Safe Prescribing Of Metformin In Diabetes

Metformin is the first-line pharmacological therapy for type 2 diabetes. It is the only glucose-lowering oral drug that has been shown to reduce mortality in patients with diabetes. The most common adverse effect is gastrointestinal upset. Starting at a low dose and increasing it slowly reduces this risk. Taking metformin with food also helps. Numerous contraindications to the use of metformin are listed in the product information, including reduced renal function. Strict adherence to these recommendations may deny a valuable drug to many patients. Introduction Metformin lowers both fasting and postprandial blood glucose. It reduces hepatic glucose output 1 and increases peripheral glucose uptake, and may delay intestinal glucose absorption. Its use is not associated with weight gain and hypoglycaemia is extremely rare when metformin is used on its own. It lowers triglyceride concentrations and has small but beneficial effects on total and high-density lipoprotein cholesterol. In the UK Prospective Diabetes Study metformin reduced diabetes-related and all-cause mortality, and reduced the risk of myocardial infarction in obese patients with type 2 diabetes when used as first-line therapy. It also reduced the risk of microvascular complications, but was no more effective than insulin or sulfonylureas. 2 A retrospective cohort study from the USA found a lower rate of hospitalisations for myocardial infarction and stroke and a reduced death rate when metformin was used first-line in type 2 diabetes in comparison with a sulfonylurea. 3 Metformin is effective when used with other glucose-lowering drugs. A standard-release (3000 mg/day maximum dose) and an extended-release preparation of metformin (2000 mg/day maximum dose) are available. The extended-release preparation can b Continue reading >>

Metformin In The Treatment Of Adults With Type 2 Diabetes Mellitus

Metformin In The Treatment Of Adults With Type 2 Diabetes Mellitus

INTRODUCTION Two classes of oral hypoglycemic drugs directly improve insulin action: biguanides (only metformin is currently available) and thiazolidinediones (TZDs). In the absence of contraindications, metformin is considered the first choice for oral treatment of type 2 diabetes (table 1). A 2006 consensus statement from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), updated regularly, proposed that metformin therapy (in the absence of contraindications) be initiated, concurrent with lifestyle intervention, at the time of diabetes diagnosis [1-3]. The pharmacology, efficacy, and side effects of metformin for the treatment of diabetes will be reviewed here. A general discussion of initial treatment of type 2 diabetes and the role of metformin in the prevention of diabetes, in the treatment of polycystic ovary syndrome, and in gestational diabetes are reviewed separately. Continue reading >>

Metformin May Be Effective In Previous Contraindications

Metformin May Be Effective In Previous Contraindications

Metformin May Be Effective in Previous Contraindications A recent review of current outcome data regarding metformin, a first-line drug for type 2 diabetes mellitus in the United States since the mid-1990s, has prompted new assessment of the drugs association with reduced mortality rates in patients with chronic kidney disease (CKD), congestive heart failure (CHF), and chronic liver disease (CLD). Concerns about lactic acidosis have limited the use of metformin in patients with CKD, CHF, and CLD. But, a safety announcement from the US Food and Drug Administration (FDA) in April 2016 allowed it to be used to treat certain patients with reduced kidney function. The review, published in the February 2017 issue of Annals of Internal Medicine , supported the FDAs decision and encouraged additional clinical trials to examine the effectiveness of the drug in the setting of previously contraindicated conditions. The review was supported by the US Veterans Affairs Administration in conjunction with the Durham Center for Health Services Research and Development in Primary Care. The systematic review examined existing studies, all-cause mortality, and major cardiovascular events in patients with CKD (estimated glomerular filtration rate < 60 mL/minute/1.73 m2), CHF, or CLD with hepatic impairment. Lead author Matthew J. Crowley, MD, a Duke endocrinologist and researcher, says the findings indicate metformin use may be associated with lower rates of mortality in patients with mild to moderate CKD, CHF, and CLD. This is an important topic for clinical practice because metformin has traditionally been withheld from patients with these conditions, and recent FDA changes may not be widely recognized, Crowley says. Theres justification now for using metformin more broadly. Crowley and Continue reading >>

Metformin

Metformin

Metformin, marketed under the trade name Glucophage among others, is the first-line medication for the treatment of type 2 diabetes,[4][5] particularly in people who are overweight.[6] It is also used in the treatment of polycystic ovary syndrome.[4] Limited evidence suggests metformin may prevent the cardiovascular disease and cancer complications of diabetes.[7][8] It is not associated with weight gain.[8] It is taken by mouth.[4] Metformin is generally well tolerated.[9] Common side effects include diarrhea, nausea and abdominal pain.[4] It has a low risk of causing low blood sugar.[4] High blood lactic acid level is a concern if the medication is prescribed inappropriately and in overly large doses.[10] It should not be used in those with significant liver disease or kidney problems.[4] While no clear harm comes from use during pregnancy, insulin is generally preferred for gestational diabetes.[4][11] Metformin is in the biguanide class.[4] It works by decreasing glucose production by the liver and increasing the insulin sensitivity of body tissues.[4] Metformin was discovered in 1922.[12] French physician Jean Sterne began study in humans in the 1950s.[12] It was introduced as a medication in France in 1957 and the United States in 1995.[4][13] It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system.[14] Metformin is believed to be the most widely used medication for diabetes which is taken by mouth.[12] It is available as a generic medication.[4] The wholesale price in the developed world is between 0.21 and 5.55 USD per month as of 2014.[15] In the United States, it costs 5 to 25 USD per month.[4] Medical uses[edit] Metformin is primarily used for type 2 diabetes, but is increasingly be Continue reading >>

Review Article Metformin In Heart Failure Patients

Review Article Metformin In Heart Failure Patients

Summary The use of metformin was considered a contraindication in heart failure patients because of the potential risk of lactic acidosis; however, more recent evidence has shown that this should no longer be the case. We reviewed the current literature and the recent guideline to correct the misconception. Continue reading >>

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