Issue 163 Item 2 Diabetes Drugs Inappropriately Prescribed

Despite explicit warnings on package inserts, metformin and thiazolidinediones are often given to diabetics hospitalized with heart failure.

Moreover, the findings indicate that inappropriate use of these drugs is rapidly increasing. 

Metformin is contraindicated for diabetics treated with heart failure medications because of the increased risk of potentially fatal lactic acidosis. Thiazolidinediones are not recommended for diabetics with advanced heart failure, out of concern that such agents could increase the intravascular volume and worsen the cardiac condition, the authors note.

To investigate the inappropriate use of these drugs, Dr. Harlan M. Krumholz, from Yale University in New Haven, Connecticut, and colleagues analyzed data from Medicaid beneficiaries with diabetes who were hospitalized with heart failure between April 1998 and March 1999 or between July 2000 and June 2001.

In the 1998-1999 cohort, 7.1% of patients received a metformin prescription, 7.2% received a thiazolidinedione prescription, and 13.5% received a prescription for either drug, the investigators note. In the 2000-2001 group, the corresponding rates were all significantly higher — 11.2%, 16.1%, and 24.4% (p < 0.001 for all).
“National guidelines do not focus extensively on the treatment of diabetes in heart failure patients,” the authors emphasize. “Future guidelines should provide more explicit guidance in defining the safe treatment” of these patients. JAMA 2003;290:81-85.

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