Renal Complications after Percutaneous Coronary Interventions on Concurrent Metformin Therapy: A Systematic Review with Meta-Analysis

Abstract

Objective: 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.Design, Setting and Participants: 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.Methods: 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.Results: Nine studies were included, totaling 2235 patients (1076 continuing metformin during the peri-procedural period), mostly with eGFR above 30 mL/min/1.73m² No cases of lactic acidosis were reported. The mean post-procedural drop in eGFR was 6.81mL/min/1.73m² (95% confidence interval [CI]: 3.41 to 10.21) in the presence of metformin and 5.34 mL/min/1.73m² (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).Conclusion: 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.

Keywords: Contrast induced nephropathy; Lactic acidosis; Metformin; Percutaneous revascularization.

Figure 1.

Schematic diagram of how the papers were sought and selected.

Figure 2.

Contrast-induced nephropathy. The incidence of contrast-induced nephropathy was not affected by continuing metformin during the peri-procedural period.

Figure 3.

Effects of baseline renal function. Post-procedural drop in estimated glomerular filtration (eGFR) in each study, depicted in relation to baseline values.

Figure 4.

Post-procedural change in estimated glomerular filtration rate: metformin (+). Based on the random-effects (RE) model, the estimated mean drop in estimated glomerular filtration rate was 6.81 ml/min/1.73 m2 in patients on metformin during the peri-procedural period. The weight, effect size (ES) and 95% confidence intervals (CI) of each study are shown on the right.

Figure 5.

Post-procedural change in estimated glomerular filtration rate: metformin (−). Based on the random-effects (RE) model, the estimated mean drop in estimated glomerular filtration rate was 5.34 ml/min/1.73 m2 in the absence of metformin during the peri-procedural period. The weight, effect size (ES) and 95% confidence intervals (CI) of each study are shown on the right.