Metformin and cardiorenal outcomes in diabetes: a reappraisal

The guidance issued to the pharmaceutical industry by the US Food and Drug Administration in 2008 has led to the publication of a series of randomised, controlled cardiovascular outcomes trials with newer therapeutic classes of glucose‐lowering medications. Several of these trials, which evaluated the newer therapeutic classes of SGLT2 inhibitors and GLP‐1 receptor agonists have reported a reduced incidence of major adverse cardiovascular and/or renal outcomes, usually relative to placebo and standard of care. Metformin was the first glucose‐lowering agent reported to improve cardiovascular outcomes in the UK Prospective diabetes Study (UKPDS) and thus became the foundation of standard care. However, as this clinical trial reported more than 20 years ago, differences from current standards of trial design and evaluation complicate comparison of the cardiovascular profiles of older and newer agents. Our article revisits the evidence for cardiovascular protection with metformin and reviews its effects on the kidney.