What are the implications of discontinuing metformin (Metformin) and starting magenta, presumably a reference to a medication, in an 82-year-old patient with diabetes, undergoing hemodialysis (Hemodialysis) due to impaired renal function, with a history of hypertensive heart disease and chronic diastolic heart failure?

From the Guidelines

Discontinuing metformin and starting a suitable alternative in this 82-year-old hemodialysis patient with diabetes, hypertensive heart disease, and chronic diastolic heart failure is recommended, but "magenta" is not a recognized diabetes medication and should not be used. Metformin should indeed be discontinued in patients on hemodialysis due to the risk of lactic acidosis, as the drug accumulates when kidney function is severely impaired 1. For a hemodialysis patient with diabetes, appropriate alternatives might include insulin therapy, GLP-1 receptor agonists like semaglutide, or DPP-4 inhibitors like linagliptin (which doesn't require dose adjustment in kidney failure) 1. The patient's heart failure also needs consideration when selecting diabetes medications, with SGLT-2 inhibitors potentially beneficial for heart failure but requiring careful monitoring in advanced kidney disease, as they have been shown to reduce the risk of heart failure hospitalization 1. Some key points to consider in managing this patient's diabetes and heart failure include:

• SGLT2 inhibitors, such as empagliflozin, have been shown to reduce the risk of heart failure hospitalization and may be beneficial in this patient population 1.
• GLP-1 receptor agonists and DPP-4 inhibitors, such as linagliptin, have a neutral effect on the risk of heart failure and may be considered as alternatives 1.
• Insulin therapy may also be considered for this patient, especially if other options are not suitable or effective 1. A nephrology and endocrinology consultation would be advisable to determine the most appropriate diabetes management strategy for this complex patient.

From the FDA Drug Label

Metformin hydrochloride tablets are contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2 Initiation of metformin hydrochloride tablets is not recommended in patients with eGFR between 30 to 45 mL/min/1. 73 m 2 In patients taking metformin hydrochloride tablets whose eGFR falls below 45 mL/min/1. 73 m 2, assess the benefit and risk of continuing therapy Age 65 or greater —The risk of metformin-associated lactic acidosis increases with the patient's age because elderly patients have a greater likelihood of having hepatic, renal, or cardiac impairment than younger patients

The patient is 82 years old and has hypertensive heart disease with chronic diastolic heart failure and is on hemodialysis, which indicates severe renal impairment. Given the patient's age and renal impairment, the risk of metformin-associated lactic acidosis is increased.

• The patient's eGFR is not provided, but given that they are on hemodialysis, it can be inferred that their renal function is severely impaired.
• The FDA drug label recommends that metformin hydrochloride tablets be contraindicated in patients with an eGFR less than 30 mL/min/1.73 m 2.
• Considering the patient's severe renal impairment and increased risk of lactic acidosis, discontinuing metformin is a reasonable decision.
• However, there is no information provided about magenta, the medication the patient is being started on, and its potential interactions or risks in this patient population 2, 2, 2.

From the Research

Discontinuation of Metformin

• The decision to discontinue metformin in an 82-year-old patient with diabetes, on hemodialysis with hypertensive heart disease and chronic diastolic heart failure, should be based on careful consideration of the patient's overall health status and medical history 3, 4, 5.
• Studies have shown that metformin can be safely discontinued in patients with type 2 diabetes mellitus and heart failure, but this decision should be made on a case-by-case basis, taking into account the patient's individual needs and health status 4, 5.
• When discontinuing metformin, it is essential to monitor the patient's blood glucose levels closely and adjust their treatment plan as needed to maintain optimal glycemic control 4, 5.

Alternative Treatments

• The patient is being started on magenta, but there is no information available on the safety and efficacy of this treatment in patients with type 2 diabetes mellitus and heart failure 3, 6.
• Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to be effective in reducing heart failure hospitalization in patients with type 2 diabetes mellitus and heart failure, and may be considered as an alternative treatment option 3, 6.

Considerations for Patients with Chronic Kidney Disease

• Metformin can be used safely in patients with chronic kidney disease (CKD), but the dosage should be adjusted individually based on the level of CKD, and the patient should be educated on sick-day management to minimize the risk of lactic acidosis 7.
• The patient's kidney function should be closely monitored, and the metformin dosage adjusted as needed to ensure safe use 7.