cardiovascular-agents and Acidosis--Lactic

Glucose-lowering treatment in patients with type 2 diabetes and heart failure is controversial. Metformin is clearly contraindicated when such diseases coexist. Conversely, no contraindications have been established for insulin in this subset of patients, even though several observational and retrospective studies have shown increased mortality and worsening heart failure. Data from the literature have demonstrated that in this patient population, which accounts for one third of all cases of heart failure, metformin reduces mortality by 14-35%. In patients with a glomerular filtration rate >30 ml/min who do not show dehydration, shock, sepsis, severe liver disease or hypoxemia, the administration of metformin doses <2 g/day was associated with a null risk of lactic acidosis. The positive effects of metformin are correlated with the reduction in insulin resistance, which is responsible for both the onset and development of heart failure in diabetic patients. Insulin can provoke severe hypoglycemia and fluid retention, resulting in negative effects. Further randomized and prospective studies are warranted to address these controversial issues in such a large population with high mortality and morbidity rates. Longitudinal studies would be crucial to the understanding of the optimal therapy and for stratification of patients according to the severity of heart failure.

Topics: Acidosis, Lactic; Cardiovascular Agents; Clinical Trials as Topic; Contraindications; Diabetes Mellitus, Type 2; Heart Failure; Hospitalization; Humans; Hypoglycemic Agents; Insulin; Kidney Diseases; Metformin; Multicenter Studies as Topic; Prospective Studies; Retrospective Studies; Risk Factors

The coronary morbi-mortality is particularly high in type 2 diabetes, which represents the vast majority of all diabetes. Hyperglycemia is an independent vascular risk factor in the short and long-term. The relationship between the degree of hyperglycemia and vascular risk is linear with no threshold effect. The occurrence of a first coronary event is an occasion, though late, to review the management of all risk factors in diabetic patients. In these patients, intensive insulin therapy administered in the acute phase of infarction reduces cardiovascular mortality by 30% at 1 and 3 years. There are no specific studies of secondary prevention by optimal therapy of diabetes, but, in the UKPDS, the treatment of hyperglycemia with sulfonylurea or insulin only marginally reduced the number of cardiovascular events. On the other hand, treatment of obese patients with metformin significantly reduced the incidence of myocardial infarction and of mortality diabetes related. These results, though observed with the same level of glycemic control as in the other treatment groups, suggest a cardio-protective effect of metformin itself. These beneficial effects should be weighed up against the potential risk of lactic acidosis which still limits the widespread use of metformin in with coronary heart disease patients. Follow-up studies show that diabetic with coronary heart disease patients do not receive all effective therapeutic inventions in secondary prevention and that the treatment of hyperglycemia is often neglected. Close collaboration between cardiologists and diabetologists is necessary to improve the management of type 2 diabetes.

Topics: Acidosis, Lactic; Acute Disease; Adrenergic beta-Antagonists; Blood Glucose; Cardiovascular Agents; Case Management; Cohort Studies; Controlled Clinical Trials as Topic; Coronary Disease; Diabetes Complications; Diabetes Mellitus; Diabetes Mellitus, Type 2; Glyburide; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Incidence; Insulin; Metformin; Myocardial Infarction; Obesity; Prospective Studies; Randomized Controlled Trials as Topic; Risk; Sulfonylurea Compounds; Treatment Outcome

Metformin is an antihyperglycemic agent commonly used in diabetic patients. It is very effective and is able to reduce the plasma glucose and HbA1C. However, in some patients, specially those with comorbidities, metformin can provoke severe lactic acidosis with high morbimortality. Treatment of the lactic acidosis induced by metformin is based on the use of supportive general measures; in severe cases, procedures of extrarrenal purification like hemodialysis or continuous hemodiafiltration have been successfully used.

Topics: Acidosis, Lactic; Acute Kidney Injury; Aged; Aged, 80 and over; Angiotensin-Converting Enzyme Inhibitors; Antidepressive Agents; Cardiovascular Agents; Cardiovascular Diseases; Coma; Diabetes Mellitus, Type 2; Drug Synergism; Drug Therapy, Combination; Emergencies; Fatal Outcome; Female; Humans; Hypoglycemic Agents; Ibuprofen; Male; Metformin; Middle Aged; Nephrology; Physician's Role; Polypharmacy