Metformin Associated With Lower Mortality in CKD, CHF and Chronic Liver Disease Interview with:

Matthew J. Crowley, MD, MHS Assistant Professor of Medicine Member in the Duke Clinical Research Institute Duke University Medical Center

Dr. Matthew Crowley

Matthew J. Crowley, MD, MHS
Assistant Professor of Medicine
Member in the Duke Clinical Research Institute
Duke University Medical Center What is the background for this study? What are the main findings?

Response: Although metformin is widely considered to be the first-line drug for type 2 diabetes, concerns about lactic acidosis have traditionally limited its use in some populations. However, FDA now indicates that metformin may be used safely for patients with mild-moderate chronic kidney disease and other historical contraindications like congestive heart failure. With the lactic acidosis question addressed for these groups, this review asked “what do we know about how metformin affects mortality and other outcomes for patients with historical contraindications and precautions?”

The main take-home message is that metformin appears associated with lower mortality in patients with mild-moderate chronic kidney disease, congestive heart failure, and chronic liver disease. What should readers take away from your report?

Response: Our findings support FDA’s recent expansion of metformin use. As we note in our review, existing studies are observational and have limitations, but overall it is very encouraging that metformin use is associated with reduced mortality for these patients with historical contraindications or precautions. What recommendations do you have for future research as a result of this study?

Response: The primary evidence in this domain is the lack of RCTs. Certain factors may reduce the feasibility of future RCTs examining metformin in these populations – for example, metformin is a generic medication widely viewed as a first-line treatment, and the time required to assess long-term outcomes like mortality may be prohibitive. The need for RCTs will be an important area for future consideration. Even without RCTs, new observational studies could ensure that deleterious outcomes do not emerge as metformin prescribing increases in populations with historical contraindications or precautions. Is there anything else you would like to add?

Response: This review was funded by the US Department of Veterans Affairs, and I am supported by a VHA HSR&D Career Development Award (CDA 13-261). Thank you for your contribution to the community.


Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease A Systematic Review Matthew J. Crowley, MD, MHS; Clarissa J. Diamantidis, MD, MHS; Jennifer R. McDuffie, PhD; C. Blake Cameron, MD, MBI; John W. Stanifer, MD, MSc; Clare K. Mock, MD; Xianwei Wang, MD; Shuang Tang, PhD; Avishek Nagi, MS; Andrzej S. Kosinski, PhD; and John W. Williams Jr., MD, MHS
Ann Intern Med. 2017;166:XXX-XXX. doi:10.7326/M16-1901

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Last Updated on January 4, 2017 by Marie Benz MD FAAD