Metformin: How Low Can You Go?

Do you have a question? Send it now... **The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS)** **What do the new NICE guidelines tell us about the changing relationship between diabetes, kidney disease and cardiovascular health?**  The updated NICE guidance on type 2 diabetes marks an important change in how clinicians should think about diabetes, kidney disease and cardiovascular risk. In this episode of *For Kidneys Sake*, Prof Jeremy Levy and Dr Andrew Frankel explore why type 2 diabetes is increasingly being approached as a cardiorenal metabolic condition rather than simply a disorder of blood glucose. They discuss the growing importance of SGLT2 inhibitors as foundational therapy and why their kidney and cardiovascular benefits remain relevant even when their glucose-lowering effects diminish as kidney function declines. Jeremy and Andrew also examine how diabetes treatment needs to adapt at different levels of kidney function, covering metformin, DPP-4 inhibitors, insulin and GLP-1 receptor agonists. They discuss when metformin should be withdrawn, why insulin requirements can change in advanced CKD, and the stronger role of GLP-1 receptor agonists for people with established cardiovascular disease. It’s a practical discussion of what the new NICE guidance means for clinicians managing the increasingly interconnected challenges of diabetes, CKD and cardiovascular disease. Key Takeaways - **Type 2 diabetes is being reframed as a cardiorenal metabolic condition**, with treatment considered alongside CKD, cardiovascular disease, heart failure and obesity. - **SGLT2 inhibitors are now foundational therapy** across multiple patient groups because of their cardiovascular and kidney benefits, rather than simply their glucose-lowering effect. - **Kidney function increasingly determines diabetes treatment.** As GFR declines, clinicians need to reconsider options including metformin, DPP-4 inhibitors and insulin. - **Insulin requirements may fall in advanced CKD.** The speakers explain that many patients may require a dose reduction as GFR falls below 20, although this needs individual adjustment. - **GLP-1 receptor agonists have an increasingly important role**, particularly for people with type 2 diabetes and established atherosclerotic cardiovascular disease. ***Resource Links:*** NICE GUIDELINES \[NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk) ***The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.*** ***The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.*** You can also join the community by signing up to our newsletter here Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub