Compared to Sulfonylureas in Patients with Impaired Kidney Function

NASHVILLE, TN—It wasn’t that many years ago that prescribing metformin for Type 2 diabetes patients with impaired kidney function was discouraged for safety reasons.

Now, in an about-face, a new VA study determined that the recommended first-line treatment for most T2D cases also significantly decreases the risk of cardiovascular events in patients with renal issues, compared to sulfonylureas.

The report from JAMA pointed out that a fifth of U.S. adults with Type 2 diabetes also have impaired kidney function and, until recently, some of the most common medications were not recommended for them. Adding to that challenge was managing their treatment to reduce cardiovascular risks, as well as lowering blood sugar, the new study suggested.1

Results from an observational study using medical record information from nearly 50,000 U.S. military veterans offered a possible solution to the quandary.

A team led by researchers from the VA Tennessee Valley VA Health Care System and Vanderbilt University Medical Center determined that metformin, which is widely recommended as a first-line drug therapy for T2D, is linked to a 20% decreased risk of major adverse cardiovascular events when compared to sulfonylureas.

The study tracked acute myocardial infarction, stroke, transient ischemic attack or cardiovascular death, determining that, with metformin, 5.8 fewer of these events per 1,000 person-years occurred vs. sulfonylureas.

Association of Treatment With Metformin vs Sulfonylurea With Major Adverse Cardiovascular Events Among Patients With Diabetes and Reduced Kidney Function
Adjusted Hazard Ratios for Major Adverse Cardiovascular Events by SubgroupsFDA indicates Food and Drug Administration. aP value for eGFR prime term (it was modeled as a spline so there are multiple terms).

“Until recently the use of metformin in patients with diabetes and impaired kidney function was cautioned against due to safety concerns,” recounted lead researcher Christianne Roumie, MD, MPH, of the VA’s Tennessee Valley Geriatric Research Education Clinical Center and VUMC. “The effectiveness of metformin demonstrated in this study will further support a potential change in prescribing practices for these patients. We believe these results should encourage providers to continue use of metformin in mild to moderate kidney disease.”

Background information in the report noted that, before 2016, prescriptions for patients with kidney disease were limited by safety concerns and because the effectiveness of metformin on clinical outcomes in patients with reduced kidney function remained unclear.

At one point, metformin was considered contraindicated in chronic kidney disease, although guidelines in the last decade were more open to permitting therapy if the glomerular filtration rate was greater than 30 mL/min. The concern was that metformin increased the risk of lactic acidosis in these patients, although past research confirmed that the condition is a rare complication—6/100,000 patient year—and that metformin-treated patients don’t appear to have a greater likelihood of developing it.

Continue Reading this Article: Major Cardiovascular Events