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Article pour les cliniciens

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Les résultats cliniques de l'utilisation de la metformine dans les populations atteintes de néphropathie chronique, d'insuffisance cardiaque congestive ou de maladie hépatique chronique: une revue systématique.

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• Crowley MJ
• Diamantidis CJ
• McDuffie JR
• Cameron CB
• Stanifer JW
• Mock CK, et al.

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Commentaires cliniques (en anglais)

Family Medicine (FM)/General Practice (GP)

The quality of evidence is low. So contrary to popular opinion, metformin is not "Vitamin F" (pre-diabetes PCOS etc), at least not yet.

Gastroenterology

This systematic review suggestd reduced all-cause mortlity in patients with histologic cirrhosis treated with metformin for type 2 diabetes mellitus. Analysis is limited to three studies but supports changes in FDA labeling for the oral hypoglycemic drug.

General Internal Medicine-Primary Care(US)

This is a helpful review, as many primary care providers may not be aware of updated FDA guidelines that have liberalized prescribing of metformin. Unfortunately, the data to support the broader guidelines are actually quite limited and more research is needed in this area to prove the effectiveness and safety of metformin for these additional populations.

General Internal Medicine-Primary Care(US)

Administrative data are not ideal for this question, but are better than nothing since it is a harm question and unlikely to be answered with an RCT. This information allows us to continue metformin for a while longer in patients with CHF, CKD or hepatic disease rather than switch to the very expensive (but effective) newer drugs.

Hospital Doctor/Hospitalists

As a hospitalist, I expected these results, but I am glad this is being investigated further to back the trend toward prescribing metformin to a wider population. I know, I have been wary and this will cause me to worry less about giving metformin to someone with a GFR between 30 and 60.

Internal Medicine

A well-designed study evaluating the strength of the research showing benefit.

Internal Medicine

This is directly in the line-of-sight for the decision-making that primary care practitioners make every day. This supports the expanded use of metformin into populations for which is has been withheld heretofore.

Nephrology

The systematic review confirms what many practitioners suspect: metformin use probably does not require the degree of prescribing caution demanded by the FDA. Synthesising the available data in one paper is useful for clinicians.

Nephrology

This study is based on studies that purposely excluded advanced CKD, so any conclusions cannot comment on the high risk of using metformin in CKD4 and CKD5. Other publications like case reports still occasionally show the risk for severe lactic acidosis, so severe that it becomes intractable even with haemodialysis. So, there is good evidence of the beneficial effect of metformin in survival of persons with diabetes with normal or mildly impaired renal function; however, because the progression of kidney disease is likely in most diabetics, there is only a window of opportunity to use metformin safely. Current guidelines acknowledge this. There is also a need for widespread use of warning information for patients about stopping metformin who are vomiting or have diarrhoea or sepsis (ie "Medicine Sick Day Rules" NHS Scotland) to prevent acidosis associated with AKI. This paper provides information but not necessarily changes for clinical practice.

Nephrology

For CKD, the level of GFR is important and the controversy and area of uncertainty lies below 30 ml/min.