Send us a text🧠 Clinical ContextWe’ve long been taught to stop metformin once GFR drops below 30 due to concerns about lactic acidosis. But what if—just maybe—some patients might actually do better by continuing it? Enter a large-scale Scottish national database review that turned this dogma on its head.🧪 Study HighlightsDesign: Retrospective analysis of a national database in ScotlandPopulation: Patients with Stage 4 and 5 CKD (GFR <30 mL/min) who continued metformin for over 6 months despite guidelinesGroup Division:Continued metformin past GFR <30Stopped metformin upon reaching GFR <30📈 OutcomesMortality:Patients who continued metformin had lower 3-year all-cause mortality compared to those who stoppedCause of Death:Leading causes in both groups: cancer, respiratory disease, cardiovascular eventsInterestingly, respiratory deaths were significantly lower in those who stayed on metforminCV Events: No significant difference in major adverse cardiovascular outcomes between the groups⚠️ CaveatsNot a randomized trial — many possible confoundersNearly half of those continuing metformin eventually stopped due to provider decision or follow-upMechanism for fewer respiratory deaths is unknown — could be unrelated or due to unmeasured factors🧩 Clinical TakeawayThis accidental natural experiment suggests we might be a bit too strict with our GFR <30 cutoff. While lactic acidosis risk is real, the data hints that patients with stable CKD might tolerate metformin better than previously thought.💡 Time to rethink? Maybe. But we still need prospective trials to safely redraw the lines. For now, this is not a green light, but definitely a yellow one.Data Source: Scottish National Database, observational cohort

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