Type-2 diabetes patients at high risk for cardiovascular events: time to challenge the ‘metformin-always first’ paradigm
Abstract
This editorial refers to ‘Novel antidiabetic drugs and risk of cardiovascular events in patients without baseline metformin use: a meta-analysis’, by W. Masson et al., pp. 69–75. Type-2 diabetes is globally ranked in the top five risk factors of mortality in both sexes, mostly related to cardiovascular diseases (CVDs).1 In high-income countries, diabetes is the 4th most contributive risk factor to cardiovascular death, as the population attributable fraction nears 8%.2 Hence, lowering the cardiovascular risk of this growing group of patients is a top priority. While the cardiovascular prevention in patients with T2D benefits greatly from targeting the usual risk factors of smoking, hypertension, and LDL-cholesterol, the use of anti-hyperglycaemia agents to reduce the cardiovascular risk has received considerable scrutiny over the last three decades. Metformin has been considered as ‘foundational’ T2D pharmacotherapy, on the basis that it also improves cardiovascular outcome. The evidence supporting metformin in terms of reducing cardiovascular events as monotherapy is solely based on a subgroup analysis of 753 overweight CVD-free patients from the UKPDS study,3 reporting respectively 39% and 36% risk reduction for MI and all-cause mortality. Besides, these results have been obtained prior to the modern cardiovascular prevention, especially before the wide use of statins, angiotensin-converting enzyme inhibitors or angiotensin receptors blockers. Hence, the incremental…
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