# Identifying high-risk combinations of metformin during COVID-19

## TL;DR

This study investigates how combining metformin with other diabetes drugs affects the risk of dying from COVID-19, finding some combinations may increase risk.

## Contribution

The study identifies specific metformin combinations associated with increased COVID-19 mortality risk, offering insights for clinical decision-making.

## Key findings

- Metformin combined with GLP-1 agonist showed highest risk of COVID-19 death (OR 2.992).
- Metformin+DPP-4 inhibitor and metformin+sulfonylurea also increased mortality risk.
- Findings suggest caution with certain metformin combinations during the pandemic.

## Abstract

There is a lack of research addressing associations of antidiabetic drug combinations with COVID-19 deaths. We examined whether adding common second-line agents to metformin was associated with COVID-19 mortality risk to inform clinical decision-making when escalating diabetes treatment.

This is a nationwide retrospective analysis covering the years 2020 and 2021. Data from the National Diabetes Registry (CroDiab) were linked to primary healthcare data, Causes of Death Registry data, and the SARS-CoV-2 vaccination database. Multivariate logistic regression models were developed for each of the combinations to compare the combination with metformin monotherapy. To address confounders, inverse probability of treatment weighting (IPTW) analysis as well as analysis with stabilized weights was performed.

Of 141014 analyzed patients, 1268 (0.90%) died of COVID-19 in 2 years. Weighted results of the drug combinations that showed statistically significant associations to COVID-19 death in comparison to metformin alone were metformin+DPP-4 inhibitor (OR 1.182, 95% CI 1.016–1.376), metformin+sulfonylurea (OR 1.195, 95% CI 1.015–1.406), and metformin+GLP-1 agonist (OR 2.992, 95% CI 2.117–4.229).

Some combinations of metformin with second-line antidiabetic drugs might require caution in the context of chronic diabetes mellitus type 2 therapy and COVID-19 related deaths. Findings should be interpreted as hypothesis-generating signals from real-world data rather than evidence of causal drug effects. Further research is needed, especially for metformin+GLP-1 agonist, as well as head-to-head comparisons of combinations therapies.