At what stage should a
patient with renal dysfunction stop medication using Metformin? To act too
conservatively, does it mean to keep the patient away from the benefits of
first-line medicine like metformin? What are the ideas of international
diabetes associations in this regard? Or what are we going to give as an
alternative?
In
recent years, it has begun to be mentioned that cutt-off values that have been used in
America for a long time (serum creatinine> 1.5 mg / dL [> 133 mmol / L]
or 1.4 mg / dL [124 mmol / L] are extremely limiting.
In the NICE guideline, in
2010, the cut-off value of creatinine determined for metformin was 150 μmol / L
(1.7 mg / dL) or the calculated GFR was <30 mL / min / 1.73 m 2.
In the Canadian guideline
published in the same year, it was suggested that if the calculated GFR <60
mL / min / 1.73 m 2, it should be used with caution and warnings, and should be
cut if the calculated GFR <30 mL / min / 1.73 m 2.
In the same year, the
Australian Diabetes Association recommends stopping the drug when the
calculated GFR <30 mL / min / 1.73 m2. Careful use of metformin has been
suggested when the calculated GFR is 45-60 mL / min / 1.73 m2 (3).
EMA (European Medicines
Agency) has informed that about one year ago, considering the European-based
considerations, the limits of renal function for metformin use could be relaxed
a little more.
The American Diabetes
Association (ADA) and the European Association for the Study of Diabetes (EASD)
have briefly addressed this issue in 2015 (4).
In the article, if the
calculated GFR is between 45-60 mL / min / 1.73 m2, it has been argued that the
prescription of metformin is not contraindicated. Even in the same article,
there are considerations for using metformin by careful follow up until the
calculated GFR <30 mL / min / 1.73 m2.It is emphasized that DPP-4 inhibitors
may be an option but dose adjustment should be considered (except for
linagliptin) for renal insufficiency.
Eventually in August 2016,
the FDA made a safety announcement for metformin. The FDA announced that
metformin could be used for mild and moderate renal insufficiency in the light of
accumulated data in the literature.
REFERANCES
1. National
Institute for Health and Clinical Excellence.The Management of Type 2 Diabetes: 2010 NICE Guidelines [Internet]. London, U.K., National Institute for Health and Clinical Excellence, 2010. Available fromhttp://www.nice.org.uk/nicemedia/live/12165/44320/44320.pdf.
Accessed 21 October 2010
2. Canadian
Diabetes Association. Clinical practice guidelines
[Internet]. 2008. Available fromhttp://www.diabetes.ca/files/cpg2008/cpg-2008.pdf.
Accessed 5 December 2010
3. National evidence based
guidelines for blood glucose control in type 2 diabetes. [Internet]. Available
fromhttp://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/di19-diabetes-blood-glucose-control.pdf.
Accessed 5 December 2010.
4. Diabetes Care. 2015;38:140-149
Some other topics in INTERNALISM
Some other topics in INTERNALISM
- Treatment of hypercalcemia,
- Metformin and renal impirment,
- PBC - Primary biliary cirrhosis,
- Giant cell arteridis:Clinical features,
- Vancomycin Resistant Enterococcus: a current overview of diagnosis, prevention and treatment,
- PAN -Diagnosis,
- Cateter Releated Bloodstream Infections-diagnosis,
- Exercise-induced hematuria
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