1 Department of Cardiology, University Hospital of Ioannina, Greece.
1 Department of Cardiology, University Hospital of Ioannina, Greece
Clin Med Res. 2023 Mar;21(1):26-35. doi: 10.3121/cmr.2022.1759.
Metformin, commonly prescribed in diabetic patients, can cause lactic acidosis. Although generally rare, this side effect remains a source of concern in procedures requiring contrast media, due to the risk of contrast-induced nephropathy. Temporarily withdrawing metformin during the peri-procedural period is often practiced, but clinical decisions are difficult in emergency situations, such as acute coronary syndromes. In this systematic review with meta-analysis, we aimed to further investigate the safety of percutaneous coronary interventions in patients on concurrent metformin therapy. We analyzed studies in patients undergoing (elective or emergency) percutaneous coronary interventions with or without concurrent metformin administration, reporting on the incidence of metformin-associated lactic acidosis and peri-procedural renal function. PubMed, ClinicalTrials.gov, Cochrane Library, and Scopus were systematically searched without language restrictions throughout August 2022. Randomized clinical trials and observational studies were assessed with the Revised Cochrane Collaboration Risk of Bias tool and the Newcastle-Ottawa quality scale, respectively. Data synthesis addressed the mean drop in estimated glomerular filtration rate (eGFR) and the incidence of contrast-induced nephropathy, in addition to lactic acidosis. Nine studies were included, totaling 2235 patients (1076 continuing metformin during the peri-procedural period), mostly with eGFR above 30 mL/min/1.73m No cases of lactic acidosis were reported. The mean post-procedural drop in eGFR was 6.81mL/min/1.73m (95% confidence interval [CI]: 3.41 to 10.21) in the presence of metformin and 5.34 mL/min/1.73m (95% CI: 2.98 to 7.70) in its absence. The incidence of contrast-induced nephropathy was not affected by concurrent metformin, as shown by a (between-groups) standardized mean difference of 0.0007 (95% CI: -0.1007 to 0.1022). Concurrent metformin during percutaneous coronary interventions in patients with relatively preserved renal function is safe, without added risk of lactic acidosis or contrast-induced nephropathy. Thus, emergency revascularization in the context of acute coronary syndromes should not be deferred. More data from clinical trials in patients with severe renal disease are needed.
二甲双胍常用于治疗糖尿病患者，但可能导致乳酸酸中毒。虽然这种副作用较为罕见，但在需要使用造影剂的检查中，它仍是导致造影剂肾病的一个隐患。因此，在围手术期通常会停用二甲双胍，但在急性冠脉综合征等紧急情况下，临床决策会比较困难。本系统回顾性Meta 分析旨在进一步探讨在接受经皮冠状动脉介入治疗的患者中同时使用二甲双胍的安全性。我们分析了接受（选择性或紧急）经皮冠状动脉介入治疗的患者的研究，这些患者同时使用或未使用二甲双胍，报告二甲双胍相关乳酸酸中毒和围手术期肾功能的发生率。在整个 2022 年 8 月，我们对 PubMed、ClinicalTrials.gov、Cochrane 图书馆和 Scopus 进行了系统搜索，没有语言限制。随机临床试验和观察性研究分别使用修订后的 Cochrane 协作风险偏倚工具和纽卡斯尔-渥太华质量量表进行评估。数据综合分析了估计肾小球滤过率（eGFR）的平均下降情况以及造影剂肾病的发生率，此外还分析了乳酸酸中毒的发生率。共纳入 9 项研究，总计 2235 例患者（1076 例在围手术期继续使用二甲双胍），eGFR 大多超过 30mL/min/1.73m。没有报告乳酸酸中毒的病例。在使用二甲双胍的情况下，术后 eGFR 的平均下降值为 6.81mL/min/1.73m（95%置信区间：3.41 至 10.21），而在未使用二甲双胍的情况下为 5.34mL/min/1.73m（95%置信区间：2.98 至 7.70）。在存在二甲双胍的情况下，造影剂肾病的发生率没有受到影响，组间标准化均数差值为 0.0007（95%置信区间：-0.1007 至 0.1022）。在肾功能相对保留的患者中，在经皮冠状动脉介入治疗期间同时使用二甲双胍是安全的，不会增加乳酸酸中毒或造影剂肾病的风险。因此，不应推迟急性冠脉综合征患者的紧急血运重建。需要更多来自严重肾功能障碍患者的临床试验数据。
