Metformin Management in Hospitalized Patients with Type 2 Diabetes
Rationale for Discontinuing Metformin
- Hospitalized patients with type 2 diabetes should have metformin discontinued due to increased risk of lactic acidosis, especially in patients with conditions that may compromise renal function, cause tissue hypoxia, or impair lactate clearance, as recommended by the American Diabetes Association 1, 2
- The risk of lactic acidosis is increased in hospitalized patients with anaerobic metabolism, impaired metformin clearance, or impaired lactic acid clearance, with a study showing an adjusted hazard ratio of 4.46 for lactic acidosis in patients with COVID-19 1, 2
Alternative Inpatient Glycemic Management
- Insulin is the preferred treatment for hyperglycemia in most hospitalized patients, with basal-bolus insulin regimen recommended for patients who are eating, and basal-plus approach for fasting patients or those undergoing procedures, according to the American Diabetes Association 2, 4, 5
Special Considerations
- In patients with stable heart failure, metformin may be continued if eGFR remains >30 mL/min/1.73 m², but should be avoided in unstable or hospitalized heart failure patients, as recommended by the American Heart Association 6
Monitoring Requirements
- Lactate concentrations should be measured in fragile patients, and kidney function should be reassessed before restarting metformin after hospitalization, as recommended by the American Diabetes Association 1, 2