Should I start metformin (biguanide) in a patient with pancreatitis interstitial, HbA1c (hemoglobin A1c) of 6.4% and a glucose level of 97 mg/dL?

From the Guidelines

I would not recommend starting metformin in this patient with interstitial pancreatitis, an HbA1c of 6.4%, and a normal fasting glucose of 97 mg/dL. The patient's values indicate prediabetes (HbA1c between 5.7-6.4%) rather than overt diabetes, and their fasting glucose is within normal range (less than 100 mg/dL) 1. Additionally, metformin is generally contraindicated in patients with acute pancreatitis due to the risk of lactic acidosis, especially if there is any compromise in renal function that often accompanies pancreatitis. For this patient, the primary focus should be on treating the underlying pancreatitis and implementing lifestyle modifications including dietary changes, weight loss if appropriate, and regular physical activity to address the prediabetic state. Some key points to consider in the management of such patients include:

• Discussing lifestyle modification, diet, weight loss, and exercise as part of shared decision-making 1
• Agreeing on the HbA1c goal and considering the initiation or continuation of metformin for most patients, with dose adjustments based on renal function 1
• Considering the use of SGLT2 inhibitors and/or GLP-1 RA for their kidney or CV benefits, taking into account the patient's eGFR 1 Once the pancreatitis has resolved, if the patient's HbA1c remains elevated or increases to diabetic range (≥6.5%), then medication therapy could be reconsidered, with metformin being the preferred initial pharmacologic agent if not contraindicated 1. Regular monitoring of both glucose levels and HbA1c every 3-6 months would be appropriate to track progression. It's also important to consider the patient's clinical characteristics, such as the presence of established ASCVD or indicators of high ASCVD risk, other comorbidities, and risk for specific adverse drug effects, as well as safety, tolerability, and cost when choosing medications 1.

From the Research

Patient Profile

• HbA1c: 6.4%
• Glucose level: 97 mg/dL
• Diagnosis: Pancreatitis interstitial

Considerations for Metformin Therapy

• According to 2, metformin can be initiated and continued concurrently with other anti-diabetic agents or insulin in patients with chronic pancreatitis, unless contraindicated or not tolerated.
• However, there are rare cases of metformin-induced pancreatitis, as reported in 3, 4, which may be precipitated by renal failure or occur even with normal dosing and no underlying chronic kidney disease.

Glycemic Control and Pancreatitis

• Elevated serum HbA1c level is a predictor of disease severity and clinical outcomes of acute pancreatitis, as shown in 5.
• The patient's HbA1c level of 6.4% is below the threshold of 6.5%, but still indicates some degree of glycemic dysregulation.
• The patient's glucose level of 97 mg/dL is within normal limits, but the presence of pancreatitis interstitial may affect glucose metabolism and increase the risk of hyperglycemia.

Treatment Approach

• Given the patient's diagnosis of pancreatitis interstitial and HbA1c level of 6.4%, careful consideration should be given to the initiation of metformin therapy, as recommended in 2.
• The patient's glucose level and HbA1c should be closely monitored, and adjustments to therapy should be made as needed to maintain optimal glycemic control, as suggested in 6.
• Alternative treatment options, such as lifestyle modifications and other anti-diabetic agents, should also be considered, as recommended in 2.