Should restrictions be relaxed for metformin use in chronic kidney disease? no, we should never again compromise safety!

Kamyar Kalantar-Zadeh, Csaba Kovesdy

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

Metformin is and has been considered as first-line therapy for type 2 diabetes for over a quarter of a century. Like other biguanides, metformin can cause a lactic acidosis that is exceptionally rare but fatal. The likelihood of metforminassociated lactic acidosis is substantially higher in patients with kidney impairment and also among thosewith seemingly normal kidney function who are at risk of acute kidney injury (AKI). Hence, regulatory agencies in many industrialized nations have maintained strict renal restrictions surrounding metformin. However, there have been millions of people exposed to metformin for many years, many of them with serum creatinine values at or close to 1.5 mg/dL with estimated glomerular filtration rates (eGFRs) much below 60 mL/min/1.73 m2 who have not developed lactic acidosis. Thus, there clearly remains controversy in this area, and there has been heightened pressure to remove the renal restrictions of metformin. To provide a discussion on the pros and cons of relaxing the renal restrictions for metformin use, we provide a Point-Counterpoint. In the point narrative below, Drs. Kalantar-Zadeh and Kovesdy provide their argument that although there is little evidence of the potential benefits of metformin in kidney disease, just considering the sheer numbers of metformin users and the high fatality rate of its associated lactic acidosis, the most appropriate practice is to avoid metformin use in people with eGFR <45 mL/min/1.73m2 or in those who are at high risk of AKI irrespective of underlying eGFR. In the following counterpoint narrative, Drs. Bakris and Molitch argue that the data from a very large analysis demonstrate clearly that serum creatinine should be supplanted with eGFR as the criteria for metformin use and that the incidence of lactic acidosis is only elevated in thosewith a reduced eGFRwho become dehydrated for various reasons or in those exposed to some toxin resulting in AKI. Otherwise the data clearly support the use of metformin under normal circumstances down to eGFR >30 mL/min/1.73 m2.

Original languageEnglish (US)
Pages (from-to)1281-1286
Number of pages6
JournalDiabetes care
Volume39
Issue number7
DOIs
StatePublished - Jul 1 2016

Fingerprint

Metformin
Chronic Renal Insufficiency
Safety
Lactic Acidosis
Kidney
Glomerular Filtration Rate
Biguanides
Kidney Diseases
Acute Kidney Injury
Developed Countries
Type 2 Diabetes Mellitus
Creatinine
Pressure

All Science Journal Classification (ASJC) codes

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism
  • Advanced and Specialized Nursing

Cite this

Should restrictions be relaxed for metformin use in chronic kidney disease? no, we should never again compromise safety! / Kalantar-Zadeh, Kamyar; Kovesdy, Csaba.

In: Diabetes care, Vol. 39, No. 7, 01.07.2016, p. 1281-1286.

Research output: Contribution to journalArticle

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