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From the Editor

October, 2015

  • 5 October

    October 6, 2015


    As a diabetes educator and pharmacist, I have had a lot of success helping patients improve their diabetes care. But at the end of the day, I get to go home diabetes free. This week, one of my pals and a pharmacist educator is sharing his professional and personal opinions ...

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October, 2015

Test Your Knowledge

Question #801

64-year female presents to your office for her 3-month follow-up. She has previously been diagnosed with mild diastolic heart failure, secondary to hypertension. She currently takes an ace-inhibitor and a diuretic with good control of her heart failure symptoms and hypertension. At her last visit, she had a FPG 118 mg/dl. In a subsequent conversation with her, you discussed how she has developed prediabetes and suggested lifestyle modifications. Since her last visit, she has taken up very gentle walking four times/week and has changed her diet to a more healthful one. Despite these positive changes, this visit's labs return an A1C 7.8%; her remaining labs are within normal limits. Which one of the following antihyperglycemic medication classes would you choose to initiate treatment?



Answer: B.  Biguanides

Metformin would be considered the first-line drug of choice for this patient. The use of metformin in patients with diabetes and heart failure used to be contraindicated (its use in patients with compromised renal function being associated with lactic acidosis). However, it can now be used in select patients with heart failure if renal function is normal, CV status is stable and ventricular dysfunction is not severe. Eurich, et al. (2005) conducted a retrospective analysis of type 2 diabetes patients treated with metformin vs. sulfonylureas and found overall decreased mortality in the metformin group. Masoudi et al (2005) examined metformin vs. thiazolidinediones and found the reduced risk of death at 1-year and lower hospital admission rates in the metformin group, while increased hospital admissions (primarily due to heart failure readmissions) was seen in the thiazolidinedione group. Thiazolidinediones increase renal sodium and water reabsorption, causing fluid retention and worsening of heart failure signs/symptoms. A recent retrospective analysis (Tzoulaki, et al., 2009) found an association between the use of sulfonylureas and increased risk of developing/worsening heart failure. Both classes of drugs should not be used in patients with diabetes and heart failure.


  1. Inzucchi S, et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35(6):1364-1379.
  2. Metformin Hydrochloride Tablets. DailyMed website. Available at http://www.fda.gov/ohrms/dockets/dailys/02/May02/053102/800471e6.pdf. Accessed Jan. 11, 2013.
  3. Inzucchi S. Metformin and heart failure: innocent until proven guilty. Diabetes Care Oct. 2005; 28(10):2585-2587. Available at http://care.diabetesjournals.org/content/28/10/2585.long#ref-24. Accessed Jan. 11, 2013.
  4. Eurich DT, Majumdar SR, McAlister FA, Tsuyuki RT, Johnson JA. Improved clinical outcomes associated with metformin in patients with diabetes and heart failure. Diabetes Care. 2005; 28:2345–2351.
  5. Johnson JA Majumdar SR, Simpson SH, Toth EL. Decreased mortality associated with metformin use compared to sulfonylurea monotherapy in type 2 diabetes mellitus. Diabetes Care. 2004; 25:2244–2248.
  6. Masoudi FA. et al. Thiazolidinediones, metformin, and outcomes in older patients with diabetes and heart failure: an observational study. Circulation. 2005; 111:583–590.
  7. Lago RM, Singh PP, Nesto RW. Congestive heart failure and cardiovascular death in patients with prediabetes and type 2 diabetes given thiazolidinediones: a meta-analysis of randomised clinical trials. Lancet. 2007; 370:1129–1136.
  8. Tzoulaki I, et al. Risk of cardiovascular disease and all-cause mortality among patients with type 2 diabetes prescribed oral antidiabetes drugs: Retrospective cohort study using U.K. general practice research database. BMJ. 2009. Available at http://www.bmj.com/content/339/bmj.b4731. Accessed Jan. 11, 2013.

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