Metformin clearance

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    Metformin clearance


    Go to: HISTORICAL PERSPECTIVE Despite these proven benefits, metformin remains contraindicated in a large segment of the type 2 diabetic population, largely because of concerns over the rare adverse effect of lactic acidosis. For these reasons, the drug has been restricted to individuals with normal creatinine levels as a surrogate for renal competence. Other contraindications (e.g., any significant hypoxemia, alcoholism, cirrhosis, a recent radiocontrast study) also increase the risk for or the consequences of lactic acidosis, but these are not the topic of this review. Metformin belongs to the biguanide drug class (previous members include phenformin and buformin), developed for lowering glucose in the 1950s. Initial enthusiasm for biguanides was tempered over the next two decades by the growing recognition of their risk of lactic acidosis. A marked reduction in biguanide use occurred in the mid-1970s because phenformin, extensively adopted in clinical practice, was implicated in a number of fatal cases of this severe metabolic decompensation (17). The association with lactic acidosis eventually led to its withdrawal from the market. The biguanide metformin (dimethylbiguanide) was initially introduced for use in the treatment of type 2 diabetes mellitus in the late 1950s. Today this drug is considered to be the first-choice agent and the “gold standard” for most people with type 2 diabetes. It has been estimated that the annual number of people receiving prescriptions for metformin worldwide is more than 120 million. The efficacy and benefits of metformin treatment in type 2 diabetes have been confirmed by large-scale studies and recognized by many consensus statements. Still, a large list of contraindications may increase the incidence of serious adverse effects, which precludes many patients from taking metformin. Three particular contraindications to the use of metformin have been suggested. They include renal impairment with elevated serum creatine levels ( more than 136 mmol/l in men and 124 mmol/l in women) or abnormal creatinine clearance, congestive heart failure requiring pharmacologic treatment and advanced age (more than 80 years of age).

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    Pharmacokinetics of metformin have only been studied in non-obese children who received metformin for early-normal onset of puberty 7. While tubular secretion is the primary route of elimination, conducted by organic cation transporters OCT2 basolateral membrane of the renal tubule cells; uptake of metformin in the renal tubule cells Renal clearance of metformin Table 2 is approximately 3.5 times greater than creatinine clearance, which indicates that tubular secretion is the major route of metformin elimination. Following oral administration, approximately 90% of the absorbed drug is eliminated via the The biguanide metformin dimethylbiguanide was initially introduced for use in. lactic acidosis a form of metabolic acidosis due to the inadequate clearance.

    In view of the increased use of metformin in obese adolescents, the aim of this study was to determine the pharmacokinetics of metformin in overweight and obese adolescents. In overweight and obese adolescents receiving metformin 500 or 1000 mg twice daily for 37 weeks during a clinical trial, blood samples were collected over 8 h during an oral glucose tolerance test. Population pharmacokinetic modeling was performed using NONMEM. Data for 22 overweight and obese adolescents with a mean total body weight (TBW) of 79.3 kg (range 54.7-104.9), body mass index (BMI) of 29.1 kg/m2 (range 22.9-39.3), and age of 15.9 years (range 11.1-17.5) were analysed. Elderly patients are more likely to have decreased renal function; contraindicated in patients with renal impairment, carefully monitor renal function in the elderly and use with caution as age increases Not for use in patients 80 years unless normal renal function established Initial and maintenance dosing of metformin should be conservative in patients with advanced age due to the potential for decreased renal function in this population Controlled clinical studies of metformin did not include sufficient numbers of elderly patients to determine whether they respond differently from younger patients Asthenia Diarrhea Flatulence Weakness Myalgia Upper respiratory tract infection Hypoglycemia GI complaints Lactic acidosis (rare) Low serum vitamin B-12 Nausea/vomiting Chest discomfort Chills Dizziness Abdominal distention Constipation Heartburn Dyspepsia 5 mmol/L), decreased blood p H, electrolyte disturbances with an increased anion gap, and an increased lactate/pyruvate ratio; when metformin is implicated as the cause of lactic acidosis, metformin plasma concentrations 5 mcg/m L are generally found Risk factors for metformin-associated lactic acidosis include renal impairment, concomitant use of certain drugs (eg, carbonic anhydrase inhibitors such as topiramate), age 65 years old or greater, having a radiological study with contrast, surgery and other procedures, hypoxic states (e.g., acute congestive heart failure), excessive alcohol intake, and hepatic impairment; if metformin-associated lactic acidosis is suspected, immediately discontinue Patients with CHF requiring pharmacologic management, in particular those with unstable or acute CHF who are at risk for hypoperfusion and hypoxemia, are at an increased risk for lactic acidosis; the risk for lactic acidosis increases with the degree of renal dysfunction and the patient’s age Do not start in patients aged 80 years or older unless Cr Cl demonstrates that renal function is not reduced, because these patients are more susceptible to developing lactic acidosis; metformin should be promptly withheld in the presence of any condition associated with hypoxemia, dehydration, or sepsis Should generally be avoided in patients with clinical or laboratory evidence of hepatic disease; patients should be cautioned against excessive alcohol intake, either acute or chronic, during metformin therapy because alcohol potentiates the effects of metformin on lactate metabolism Discontinue metformin at the time of or before an iodinated contrast imaging procedure in patients with an e GFR between 30-60 m L/minute/1.73 m²; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinate contrast The onset of lactic acidosis often is subtle and accompanied by nonspecific symptoms (eg, malaise, myalgias, respiratory distress, increasing somnolence, nonspecific abdominal distress); with marked acidosis, hypothermia, hypotension, and resistant bradyarrhythmias may occur; patients should be instructed regarding recognition of these symptoms and told to notify their physician immediately if the symptoms occur; metformin should be withdrawn until the situation is clarified; serum electrolytes, ketones, blood glucose, and, if indicated, blood p H, lactate levels, and even blood metformin levels may be useful Once a patient is stabilized on any dose level of metformin, GI symptoms, which are common during initiation of therapy, are unlikely to be drug related; later occurrences of GI symptoms could be due to lactic acidosis or other serious disease Lactic acidosis should be suspected in any diabetic patient with metabolic acidosis who is lacking evidence of ketoacidosis (ketonuria and ketonemia); lactic acidosis is a medical emergency that must be treated in a hospital setting; in a patient with lactic acidosis who is taking metformin, the drug should be discontinued immediately and general supportive care measures promptly instituted; metformin is highly dialyzable (clearance up to 170 m L/min under good hemodynamic conditions); prompt hemodialysis is recommended to correct the acidosis and to remove the accumulated metformin; such management often results in prompt reversal of symptoms and recovery Increased risk of severe hypoglycemia especially in elderly, debilitated or malnourished, adrenal or pituitary insufficiency, dehydration, heavy alcohol use, hypoxic states, hepatic/renal impairment, stress due to infection, fever, trauma, or surgery Concomitant administration of insulin and insulin secretagogues (e.g., sulfonylurea) may increase risk of hypoglycemia; therefore, a lower dose of insulin or insulin secretagogue may be required to minimize risk of hypoglycemia when used in combination with metformin Withholding of food and fluids during surgical or other procedures may increase risk for volume depletion, hypotension, and renal impairment; therapy should be temporarily discontinued while patients have restricted food and fluid intake Rare lactic acidosis may occur due to metformin accumulation; fatal in approximately 50% of cases; risk increases with age, degree of renal dysfunction, and with unstable or acute CHF; if metformin-associated lactic acidosis suspected, general supportive measures should be instituted promptly in a hospital setting, along with immediate discontinuation of therapy; in patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct acidosis and remove accumulated metformin (metformin hydrochloride is dialyzable, with a clearance of up to170 m L/minute under good hemodynamic conditions); hemodialysis has often resulted in reversal of symptoms and recovery Possible increased risk of CV mortality May cause ovulation in anovulatory and premenopausal PCOS patients May be necessary to discontinue therapy with metformin and administer insulin if patient is exposed to stress (fever, trauma, infection), or experiences diabetic ketoacidosis Several of the postmarketing cases of metformin-associated lactic acidosis occurred in setting of acute congestive heart failure (particularly when accompanied by hypoperfusion and hypoxemia); cardiovascular collapse (shock) acute myocardial infarction, sepsis, and other conditions associated with hypoxemia have been associated with lactic acidosis and may also cause prerenal azotemia; discontinue therapy when such events occur May impair vitamin B12 or calcium intake/absorption; monitor B12 serum concentrations periodically with long-term therapy Not indicated for use in patients with type 1 diabetes mellitus that are insulin dependent due to lack of efficacy Withhold in patients with dehydration and/or prerenal azotemia Conclusive evidence of macrovascular risk reduction with metformin not established Limited data with in pregnant women are not sufficient to determine drug-associated risk for major birth defects or miscarriage; published studies with metformin use during pregnancy have not reported a clear association with metformin and major birth defect or miscarriage risk; poorly-controlled diabetes mellitus in pregnancy increases maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, stillbirth and delivery complications; poorly controlled diabetes mellitus increases the fetal risk for major birth defects, stillbirth, and macrosomia related morbidity Limited published studies report that metformin is present in human milk; however, there is insufficient information to determine effects of metformin on breastfed infant and no available information on effects of metformin on milk production; therefore, developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and any potential adverse effects on breastfed child from therapy or from the underlying maternal condition The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

    Metformin clearance

    METFORMIN ER 750 MG- metformin er 750 mg tablet, Metformin Hydrochloride Extended-Release Tablets 500 mg and.

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  7. Use of Metformin in the Setting of Mild-to-Moderate Renal Insufficiency. clearance of metformin highly correlated with creatinine clearance CrCl; r = 0.85,

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    Postmarketing cases of metformin-associated lactic acidosis have resulted in death. Drugs that reduce metformin clearance such as ranolazine, vandetanib. Objective We aimed to estimate the metformin-associated lactic acidosis MALA risk by assessing retrospectively the renal clearance variability and applying a. Metformin is used in type 2 diabetes mellitus to decrease the amount of glucose produced by the liver and to increase the body’s response to insulin. In patients with renal failure acute or chronic, the renal clearance of metformin is decreased, and there is an associated risk of lactic acidosis.

     
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