Reader Response: Association of Prestroke Metformin Use, Stroke Severity, and Thrombolysis Outcome
Abstract
When I first read the article by Westphal et al.,1 I was excited about the possible positive effects of metformin on stroke. I note that a one-point difference in NIHSS is not clinically significant, a one-point change in modified Rankin Score is somewhat significant, and 13% vs 18% death rate is more clinically significant. However, further critical analysis challenges this interpretation. First, the authors conclude that “[t]his suggests a protective effect of MET [metformin].” Neurology reviewers and editors should admonish authors about inferring causality from inappropriately designed studies. In addition, as the authors report, “The number of confounders in this study was 19; together with the treatment group (MET+/MET−), 20 independent variables resulted.” This can only partially be compensated by their propensity score matching and multiple imputation. I would point out several other problems. For example, missing values included international normalized ratio (INR) on admission (29.7%). How could this be if everyone got IV thrombolysis? Per the article by Scheitz et al. cited in reference 8, “Laboratory measures obtained on hospital admission include glucose (mmol/L), blood cell counts (platelets, hemoglobin, and leucocytes), international normalized ratio and partial thromboplastin time/ Not all centers have to provide data on all variables but have given a commitment to add missing variables retrospectively, if considered relevant to answer a specific research…
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