This is an application for a K08 Career Development Award for Carlos Alvarez, an Assistant Professor and clinical pharmacist at Texas Tech University Health Sciences Center School of Pharmacy. His long-term career goal is to be an internationally known expert and independent investigator in the pharmacoepidemiology of therapeutic agents used in patients with type 2 diabetes and chronic kidney disease. The career development aims of this K08 application are to support training in:
Aim 1) pharmacoepidemiology, Aim 2) health services research, and Aim 3) analysis of large, complex national databases. This career development award will also support Dr. Alvarez's path to independence. To achieve this goal, Dr. Alvarez has assembled a multidisciplinary mentoring and advisory team with significant experience in extramurally funded clinical research. Chronic kidney disease (CKD) is a common and well known complication of type 2 diabetes (T2DM). This complication often restricts providers from prescribing metformin, a glucose-lowering agent with known morbidity and mortality benefits in patients with T2DM. This FDA labeled contraindication for metformin using arbitrary serum creatinine cut-points in patients with T2DM and CKD is not evidence based and often necessitates prescribers to initiate or switch patients to other glucose-lowering agents with worse adverse event profiles or that have been associated with poor cardiac outcomes. Guidance in other countries do not endorse the FDA contraindication and allows for metformin use in patients with mild to moderate CKD as measured by estimated glomerular filtration rate. This recommendation is also not based in evidence. Thus, the safety and effectiveness of metformin in patients with T2DM and CKD is largely unknown. Dr. Alvarez's research will focus on determining the safety and effectiveness through three specific research aims.
In Aim 1 he will determine patterns of metformin use in patients with T2DM and CKD. He will analyze complex administrative and clinical data from the national VA database hosted by VINCI. Patterns identified in Aim 1 will inform him of the variables that should be further tested in Aims 2 and 3.
Aim 2 will examine associations of adverse events for metformin and other glucose-lowering agents. Specifically, he will study incident hospitalizations for lactic acidosis and primary hospitalizations or emergency department visits for hypoglycemia.
In Aim 3, Dr. Alvarez will assess the relationship between metformin and the development of microvascular and macrovascular outcomes. Microvascular outcomes assessed will be the development of proliferative diabetic retinopathy and progression of kidney disease. Macrovascular outcomes will be measured as a composite of non-fatal stroke, acute myocardial infarction, non-traumatic lower extremity amputation and cardiovascular disease death. He will also compare glycemic control between patients prescribed metformin and those on other glucose-lowering agents. Innovative techniques such as combination high-dimensional propensity score and instrumental variable modeling will be used in Aims 2 and 3 to reduce bias often encountered in observational research. The research will form the basis for an R01 or equivalent application to compare metformin usage patterns, safety and effectiveness in patients with type 2 diabetes and chronic kidney disease between those treated in the VA system and the United Kingdom.

Public Health Relevance

The epidemic of type 2 diabetes (T2DM) and chronic kidney disease (CKD) is on the rise. Unfortunately, metformin, a drug with known benefits in patients with T2DM, has a FDA labeled contraindication in patients with T2DM and CKD. This contraindication is not based on clinical evidence;rather, it is based on previous poor experience with an older drug in the same therapeutic class, phenformin, which has been removed from the market. Despite this contraindication, evidence suggests that patients with T2DM and CKD are still prescribed metformin. It is critical to understand the safety and effectiveness of metformin in this population as it may affect policy and labeling changes on how it is prescribed.

National Institute of Health (NIH)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Clinical Investigator Award (CIA) (K08)
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Study Section
Digestive Diseases and Nutrition C Subcommittee (DDK)
Program Officer
Hyde, James F
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Texas Tech University
Other Health Professions
Schools of Pharmacy
United States
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Makris, Una E; Alvarez, Carlos A; Wei, Wei et al. (2017) Association of Statin Use With Risk of Back Disorder Diagnoses. JAMA Intern Med 177:1044-1046
Yeung, Denise L; Alvarez, Kristin S; Quinones, Marissa E et al. (2017) Low-health literacy flashcards & mobile video reinforcement to improve medication adherence in patients on oral diabetes, heart failure, and hypertension medications. J Am Pharm Assoc (2003) 57:30-37
Murphy, Caitlin C; Tiro, Jasmin A; Jean, Gary W et al. (2017) High Initiation of Adjuvant Hormonal Therapy Among Uninsured Stages I-III Breast Cancer Patients Treated in a Safety-Net Healthcare System. J Womens Health (Larchmt) 26:655-661
Mathew, Stacy; Chamberlain, Carol; Alvarez, Kristin S et al. (2016) Impact of a Pharmacy-Led Pain Management Team on Adults in an Academic Medical Center. Hosp Pharm 51:639-645
Faust, Andrew C; Rajan, Pearl; Sheperd, Lyndsay A et al. (2016) Impact of an Analgesia-Based Sedation Protocol on Mechanically Ventilated Patients in a Medical Intensive Care Unit. Anesth Analg 123:903-9
Clifford, Kalin M; Dy-Boarman, Eliza A; Haase, Krystal K et al. (2016) Challenges with Diagnosing and Managing Sepsis in Older Adults. Expert Rev Anti Infect Ther 14:231-41
Alvarez, Carlos A; Neeland, Ian J; McGuire, Darren K (2015) Sodium-glucose co-transporter inhibition in the treatment of diabetes: sweetening the pot. Diab Vasc Dis Res 12:74-7
Makris, Una E; Pugh, Mary Jo; Alvarez, Carlos A et al. (2015) Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain. Am J Med Sci 350:279-85
Alvarez, C A; Lingvay, I; Vuylsteke, V et al. (2015) Cardiovascular Risk in Diabetes Mellitus: Complication of the Disease or of Antihyperglycemic Medications. Clin Pharmacol Ther 98:145-61
Kumbhani, Dharam J; Marso, Steven P; Alvarez, Carlos A et al. (2015) State-of-the-Art: Hypo-responsiveness to oral antiplatelet therapy in patients with type 2 diabetes mellitus. Curr Cardiovasc Risk Rep 9:4