A Study of Associations Between Plasma Metformin Concentration, Lactic Acidosis, and Mortality in an Emergency Hospitalization Context

A 43-year-old woman was brought to the hospital with severe metabolic acidosis (pH 6.56, bicarbonate 3 mmol/L, and lactate 18.4 mmol/L) and a serum creatinine of 162 μmol/L with a serum potassium of 7.8 mmol/L. A delayed diagnosis of metformin-associated lactic acidosis was made, and she was treated with tris-hydroxymethyl aminomethane (THAM) and renal replacement therapy (RRT). Following a complete recovery, she admitted to ingesting 180 tablets (90 grams) of metformin. Her peak serum metformin concentration was 170 μg/mL (therapeutic range 1-2 μg/mL). Our case demonstrates an intentional metformin overdose resulting in lactic acidosis in a nondiabetic patient who was successfully treated with THAM and RRT.

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Recurrent lactic acidosis and hypoglycemia with inadvertent metformin use: a case of look-alike pills

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-17-0148 ◽

2017 ◽

Vol 2017 ◽

Cited By ~ 2

Author(s):

Tess Jacob ◽

Renee Garrick ◽

Michael D Goldberg

Keyword(s):

Lactic Acidosis ◽

Treated Patient ◽

Significant Risk ◽

Systemic Absorption ◽

Intermittent Hemodialysis ◽

List Type ◽

First Line ◽

Metformin Concentration ◽

Toxic Ingestion ◽

Complex Relationships

Summary Metformin is recommended as the first-line agent for the treatment of type 2 diabetes. Although this drug has a generally good safety profile, rare but potentially serious adverse effects may occur. Metformin-associated lactic acidosis, although very uncommon, carries a significant risk of mortality. The relationship between metformin accumulation and lactic acidosis is complex and is affected by the presence of comorbid conditions such as renal and hepatic disease. Plasma metformin levels do not reliably correlate with the severity of lactic acidosis. We present a case of inadvertent metformin overdose in a patient with both renal failure and hepatic cirrhosis, leading to two episodes of lactic acidosis and hypoglycemia. The patient was successfully treated with hemodialysis both times and did not develop any further lactic acidosis or hypoglycemia, after the identification of metformin tablets accidentally mixed in with his supply of sevelamer tablets. Early initiation of renal replacement therapy is key in decreasing lactic acidosis-associated mortality. Learning points: When a toxic ingestion is suspected, direct visualization of the patient’s pills is advised in order to rule out the possibility of patient- or pharmacist-related medication errors. Though sending a specimen for determination of the plasma metformin concentration is important when a metformin-treated patient with diabetes presents with lactic acidosis, complex relationships exist between metformin accumulation, hyperlactatemia and acidosis, and the drug may not always be the precipitating factor. Intermittent hemodialysis is recommended as the first-line treatment for metformin-associated lactic acidosis (MALA). An investigational delayed-release form of metformin with reduced systemic absorption may carry a lower risk for MALA in patients with renal insufficiency, in whom metformin therapy may presently be contraindicated.

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Reversible Total Vision Loss Caused by Severe Metformin-associated Lactic Acidosis: A Case Report

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2021.3.51141 ◽

2021 ◽

Vol 2 (5) ◽

pp. 206-209

Author(s):

Andrew Koons ◽

Alexandra Amaducci ◽

Kenneth Katz

Keyword(s):

Diabetes Mellitus ◽

Emergency Department ◽

Case Report ◽

Lactic Acidosis ◽

Visual Loss ◽

Vision Loss ◽

Hospital Emergency Department ◽

Type Ii ◽

Hospital Emergency ◽

Metformin Concentration

Introduction: Metformin is a biguanide used to treat diabetes mellitus (DM). Metformin-associated lactic acidosis (MALA) carries a high mortality and can occur in patients with renal failure from drug bioaccumulation. Reversible vision loss is a highly unusual, rarely reported complication of MALA. We present a case of a patient whose serum metformin concentration was unusually high and associated with vision loss. Case Report: A 60-year-old woman presented to an outside hospital emergency department with acute vision loss after being found at home confused, somnolent, and hypoglycemic, having last being seen normal two days prior. She reported vomiting and diarrhea during that time and a recently treated urinary tract infection. The visual loss resolved with continuous renal replacement therapy. Conclusion: This novel case of a patient with Type II DM prescribed metformin and insulin who developed reversible vision loss while suffering from MALA highlights the potential for vision loss in association with MALA.

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A fatal autopsy case of metformin-associated lactic acidosis and respiratory failure with proven high plasma metformin concentration

Journal of the Japanese Society of Intensive Care Medicine ◽

10.3918/jsicm.28_532 ◽

2021 ◽

Vol 28 (6) ◽

pp. 532-536

Author(s):

Ryo Totsuka ◽

Hidetaka Suzuki ◽

Fumiko Aihara ◽

Urara Sakurai ◽

Kazuhiro Matsuo ◽

...

Keyword(s):

Respiratory Failure ◽

Lactic Acidosis ◽

High Plasma ◽

Autopsy Case ◽

Metformin Concentration

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Lactic Acidosis in Metformin Therapy: Relationship between plasma metformin concentration and renal function

Diabetes Care ◽

10.2337/diacare.21.8.1366 ◽

1998 ◽

Vol 21 (8) ◽

pp. 1366-1367 ◽

Cited By ~ 19

Author(s):

J. D. Lalau ◽

J.-M. Race ◽

L. Brinquin

Keyword(s):

Renal Function ◽

Lactic Acidosis ◽

Metformin Therapy ◽

Therapy Relationship ◽

Metformin Concentration

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Metformin-Induced Lactic Acidosis: A Question of Time

Case Reports in Critical Care ◽

10.1155/2020/6962591 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Céline Bellefroid ◽

Pierre Goffin ◽

Julien Guntz ◽

Marine Deville

Keyword(s):

Lactic Acidosis ◽

Type Ii Diabetes ◽

High Flow ◽

Type Ii ◽

Severe Lactic Acidosis ◽

Oral Antidiabetic ◽

Metformin Concentration ◽

Life Threatening

Metformin is an oral antidiabetic largely prescribed in the treatment of type II diabetes. Overdose is associated with life-threatening lactic acidosis. We report the case of the highest metformin concentration ever described secondary to a voluntary suicidal intake. The patient developed a severe lactic acidosis and hemodynamic shock successfully treated with high-flow hemofiltration. Time to start extrarenal epuration is capital to avoid poor evolution.

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Early Initiation of Hemodialysis for Progressive Lactic Acidosis in a Diabetic Patient

Case Reports in Acute Medicine ◽

10.1159/000495198 ◽

2018 ◽

Vol 1 (1-3) ◽

pp. 17-20

Author(s):

Keisuke Nyunoya ◽

Naoki Hayase ◽

Kent Doi ◽

Toshifumi Asada ◽

Yoshihiro Ueda ◽

...

Keyword(s):

Intensive Care ◽

Lactic Acidosis ◽

Altered Mental Status ◽

Early Initiation ◽

Critical Conditions ◽

Diabetic Patients ◽

Severe Lactic Acidosis ◽

Metformin Concentration ◽

History Of ◽

Lactate Levels

Metformin, a widely used medicine for diabetes mellitus, is well known to cause lactic acidosis, which may require intensive care, including hemodialysis, especially in severe cases because of the high mortality rate. Because metformin is effectively removed by renal replacement therapy, early initiation of hemodialysis is crucial for metformin overdose. We report a case of a 38-year-old male who was brought to our emergency department (ED) with altered mental status. He subsequently developed severe lactic acidosis with a peak lactate level of 33.4 mmol/L. No clear etiology was identified for these critical conditions at the ED. Although metformin intoxication could not be confirmed at this time, we decided to start hemodialysis immediately. Soon after hemodialysis, blood pH and lactate levels dramatically improved. The patient fully recovered after 9 days of intensive care unit (ICU) stay. Later on, his serum metformin concentration was revealed to be 146 μg/mL and 26 μg/mL at ICU admission and after dialysis at day 3, respectively (therapeutic range, 1–2 μg/mL). Early initiation of hemodialysis might be beneficial for diabetic patients with unexplained severe lactic acidosis despite uncertainties in history of overdose or serum concentration of metformin.

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