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

2017 ◽  
Vol 2017 ◽  
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.

Proposal for the administration of metformin in patients with chronic kidney disease

2012 ◽  
Vol 153 (39) ◽  
pp. 1527-1535 ◽  
Author(s):  
Zoltán Balogh ◽  
János Mátyus
Keyword(s):  
Lactic Acidosis ◽  
Chronic Renal Disease ◽  
Antidiabetic Agent ◽  
First Line ◽  
Oral Antidiabetic Agent ◽  
Oral Antidiabetic ◽  
Cardiovascular Morbidity And Mortality ◽  
Glomerular Filtrate ◽  
Life Threatening

Metformin is the first-line, widely used oral antidiabetic agent for the management of type 2 diabetes. There is increasing evidence that metformin use results in a reduction in cardiovascular morbidity and mortality, and might have anticancer activity. An extremely rare, but potentially life-threatening adverse effect of metformin is lactic acidosis, therefore, its use is traditionally contraindicated if the glomerular filtrate rate is below 60 mL/min. However, lactic acidosis is always associated with acute events, such as hypovolemia, acute cardiorespiratory illness, severe sepsis and acute renal or hepatic failure. Furthermore, administration of insulins and conventional antihyperglycemic agents increases the risk of severe hypoglycemic events when renal function is reduced. Therefore, the magnitude of the benefit of metformin use would outweigh potential risk of lactic acidosis in moderate chronic renal disease. After reviewing the literature, the authors give a proposal for the administration of metformin, according to the calculated glomerular filtrate rate. Orv.Hetil., 2012, 153, 1527–1535.

scholarly journals Dutch Breast Cancer Trialists' Group (BOOG)

2006 ◽  
Vol 9 (S1) ◽  
pp. 61-79
Author(s):  
Keyword(s):  
Breast Cancer ◽  
Clinical Trials ◽  
Metastatic Breast Cancer ◽  
Endocrine Therapy ◽  
Metastatic Breast ◽  
Phase Iii ◽  
List Type ◽  
First Line ◽  
Open Label ◽  
Phase Iii Study

This section provides current contact details and a summary of recent or ongoing clinical trials being coordinated by Dutch breast cancer trialists' group (BOOG). Clinical trials include:An open label randomized (inter)national multicenter comparative trial of 5 years adjuvant endocrine therapy with an LHRH agonist plus an aromatase inhibitor (goserelin + anastrozole) versus five courses FE90C chemotherapy followed by the same endocrine therapy in pre- or perimenopausal patients with hormone receptor-positive primary breast cancer (PRemenopausal Optimal Management IS Endocrine therapy). BOOG 2002-01/PROMISE. ISRCTN23561723Open label, comparative, randomized, multicenter, study of trastuzumab (Herceptin) given with docetaxel (Taxotere) versus sequential single agent therapy with trastuzumab followed by docetaxel as first-line treatment for metastatic breast cancer (MBC) patients with HER2neu overexpression. BOOG 2002-02/HERTAX ISRCTN13770586Micro-metastases and Isolated tumour cells: Robust and Relevant Or Rubbish? The MIRROR study in BREAST CANCER. BOOG 2003-03/ZonMW 3214Radiation dose intensity study in breast cancer in young women: a randomized phase III trial of additional dose to the tumor bed. BOOG 2004-01/Young Boost SRCTN45066831Microarray analysis in breast cancer to Tailor Adjuvant Drugs Or Regimens, a randomized phase III study. MATADOR, BOOG 2005-02, CKTO 2004-04 ISRCTN61893718A prospective randomised, open, multicentre, phase III study to assess different Durations of Anastrozole therapy after 2–3 years Tamoxifen as Adjuvant therapy in postmenopausal women with breast cancer. 2006-01/DATAA randomized, open-label phase III study of first line chemotherapy in elderly metastatic breast cancer patients, comparing intravenous pegylated liposomal doxorubicin with oral capecitabine; and the incorporation of a complete geriatric assessment. 2006-02/OMEGABOOG participation in International studies:. BOOG 2001-01/TEAM trial. BOOG 2001-02/AMAROS (EORTC 10981/22023). BOOG 2002-04/HERA (BIG 1-01/EORTC 10011/BO16348B). BOOG 2003-02 (BIG 1-02/IBCSG 27-02). BOOG 2003-04 (GBG 29). BOOG 2004-02/TBP (GBG 26, BIG 3-05). BOOG 2005-01/CASA (IBCSG 32-05/BIG 1-05). BOOG 2005-03/MINDACT (EORTC 10041, BIG 3-04). BOOG 2006-03/SUPREMO (BIG 2-04). BOOG 2006-04/Adjuvant lapatinib study (BIG 2-06/EGF106708)

Preference for Fasciocutaneous Flap Over Musculocutaneous Flap as a First-Line Option for Ischial Pressure Wound Reconstruction: A Review of 64 Cases

2021 ◽  
pp. 153473462110387
Author(s):  
Jaehoon Choi ◽  
Kyubeom Kim ◽  
Junhyung Kim ◽  
Woonhyeok Jeong ◽  
Taehee Jo ◽  
...  
Keyword(s):  
Dead Space ◽  
Postoperative Bleeding ◽  
Significant Risk ◽  
Distal Portion ◽  
Complete Healing ◽  
Fasciocutaneous Flap ◽  
Musculocutaneous Flap ◽  
First Line ◽  
Fasciocutaneous Flaps ◽  
Significant Difference

The ischial pressure wound usually comprises a large, extensive defect and involves the repair of more than a small opening. Most surgeons have used a musculocutaneous flap to fill the large dead space of an ischial pressure wound. However, sacrificing muscle tissue has a potential risk of postoperative bleeding. The transferred muscle ultimately loses function as a cushion to absorb pressure. Conservation of muscle structures may be beneficial for use in future recurrence, which is common with ischial pressure wound. We compared the difference in outcome between musculocutaneous and fasciocutaneous flaps and analyzed factors affecting complications with the flaps in ischial pressure wound reconstruction. This study reviewed the results of 64 flaps in 44 patients with ischial wounds. The wounds were reconstructed with 34 musculocutaneous flaps (53%) and 30 fasciocutaneous flaps (47%). Twenty-three cases (36%) had complete healing, and 41 (64%) had complications. There was no significant difference in outcomes between fasciocutaneous and musculocutaneous flap groups. Crude logistic regression analysis showed no significant risk factors for occurrence of major complications. When fasciocutaneous flaps were used, the neighboring perforators and muscle tissues could be conserved. With a perforator-based fasciocutaneous flap, a de-epithelized distal portion of the flap could be used to fill the dead space. Therefore, the fasciocutaneous flap may have priority over the musculocutaneous flap as a first-line option for ischial pressure wound reconstruction.

Prevalence and Risk Factors Associated with First-Line Anti-Tuberculosis Induced Hepatotoxicity in Suratthani Hospital, Thailand

2021 ◽  
Vol 104 (2) ◽  
pp. 233-239
Keyword(s):  
Risk Factors ◽  
Serum Albumin ◽  
Clinical Symptoms ◽  
Significant Risk ◽  
Public Health Problem ◽  
Major Public Health Problem ◽  
First Line ◽  
Drug Induced ◽  
Factors Associated ◽  
Drug Risk

ackground: Tuberculosis (TB) is a major public health problem, including Thailand. Anti-TB drugs are very effective treatment, but they can cause hepatotoxicity. Data on the prevalence of anti-TB drug-induced hepatotoxicity (DIH), as well as the contributing risk factors, are scarce in Thailand. Objective: To measure the prevalence and identify risk factors associated with first-line drugs (FLD) induced hepatoxicity in TB patients. Materials and Methods: The present study was a retrospective study design in TB clinic of Suratthani Hospital, in Southern Thailand. All patients diagnosed with TB and received FLD between January and December 2017, were eligible for the study. Hepatoxicity defined as the following criteria: serum aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels >5x upper limit of normal (ULN) without symptoms, or AST or ALT >3x ULN with clinical symptoms. Results: Of all the 198 TB cases, 18 were identified as DIH. Prevalence of DIH was 9.1%. Hepatitis after FLD was independently associated with age>60 years (adjusted OR [aOR] 28.49, 95% CI 2.68 to 302.95, p=0.005) and serum albumin <3.5 g/dL (aOR 20.97, 95% CI 2.11 to 208.51, p=0.009). Conclusion: Age of more than 60 years and low serum albumin of less than 3.5 g/dL were significant risk factors associated with first-line anti-TB drugs induced hepatoxicity. Keywords: Hepatoxicity, Anti-tuberculosis drug, Risk factor, Thailand

Therapist beliefs about exposure therapy implementation

2020 ◽  
Vol 13 ◽  
Author(s):  
Johanna M. Meyer ◽  
Peter J. Kelly ◽  
Brett J. Deacon
Keyword(s):  
Online Survey ◽  
Exposure Therapy ◽  
List Type ◽  
First Line ◽  
Therapy Training ◽  
Negative Beliefs ◽  
Cognitive Behavioural ◽  
Effective Manner ◽  
The Relationship ◽  
Safety Behaviour

Abstract Exposure therapy is consistently indicated as the first-line treatment for anxiety-related disorders. Unfortunately, therapists often deliver exposure therapy in an overly cautious, less effective manner, characterized by using their own ‘therapist safety behaviours’. Cognitive behavioural models postulate that beliefs about therapist safety behaviours are related to their use; however, little is known about the beliefs therapists hold regarding therapist safety behaviour use. The present study aimed to identify the beliefs exposure therapists have regarding the necessity of therapist safety behaviours and to examine the relationship between this construct and therapist safety behaviour use. Australian psychologists (n = 98) completed an online survey that included existing measures of therapist safety behaviour use, therapist negative beliefs about exposure therapy, likelihood to exclude anxious clients from exposure therapy, and use of intensifying exposure techniques. Participants also completed the Exposure Implementation Beliefs Scale (EIBS), a measure created for the present study which assesses beliefs regarding the necessity of therapist safety behaviours. Beliefs about the necessity of therapist safety behaviours – particularly in protecting the client – significantly predicted therapist safety behaviour use. Findings suggest that exposure therapy training media should aim to decrease therapist safety behaviour use by addressing beliefs about the necessity of therapist safety behaviours, especially in protecting the client. Key learning aims (1) To understand what therapist safety behaviours are in the context of exposure therapy. (2) To identify common beliefs about therapist safety behaviours. (3) To understand how beliefs about therapist safety behaviours relate to therapist safety behaviour use. (4) To consider how exposure therapy delivery may be improved by modifying beliefs about therapist safety behaviours. (5) To explore how beliefs about therapist safety behaviours may be modified to reduce therapist safety behaviour use.

scholarly journals Mitochondrial disease: an uncommon but important cause of diabetes mellitus

2018 ◽  
Vol 2018 ◽  
Author(s):  
Ming Li Yee ◽  
Rosemary Wong ◽  
Mineesh Datta ◽  
Timothy Nicholas Fazio ◽  
Mina Mohammad Ebrahim ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Weight Loss ◽  
Lactic Acidosis ◽  
Superior Mesenteric Artery ◽  
Mesenteric Artery ◽  
Mitochondrial Disorder ◽  
Superior Mesenteric Artery Syndrome ◽  
List Type ◽  
Presenting Symptoms ◽  
History Of

Summary Mitochondrial diseases are rare, heterogeneous conditions affecting organs dependent on high aerobic metabolism. Presenting symptoms and signs vary depending on the mutation and mutant protein load. Diabetes mellitus is the most common endocrinopathy, and recognition of these patients is important due to its impact on management and screening of family members. In particular, glycemic management differs in these patients: the use of metformin is avoided because of the risk of lactic acidosis. We describe a patient who presented with gradual weight loss and an acute presentation of hyperglycemia complicated by the superior mesenteric artery syndrome. His maternal history of diabetes and deafness and a personal history of hearing impairment led to the diagnosis of a mitochondrial disorder. Learning points: The constellation of diabetes, multi-organ involvement and maternal inheritance should prompt consideration of a mitochondrial disorder. Mitochondrial encephalomyopathy, lactic acidosis, stroke-like episodes (MELAS) and maternally inherited diabetes and deafness (MIDD) are the most common mitochondrial diabetes disorders caused by a mutation in m.3243A>G in 80% of cases. Metformin should be avoided due to the risk of lactic acidosis. There is more rapid progression to insulin therapy and higher prevalence of diabetic complications compared to type 2 diabetes. Diagnosis of a mitochondrial disorder leads to family screening, education and surveillance for future complications. Superior mesenteric artery syndrome, an uncommon but important cause of intestinal pseudo-obstruction in cases of significant weight loss, has been reported in MELAS patients.

Randomized double blind (DB) placebo (Plcb) controlled phase III study assessing the efficacy of xaliproden (X) in reducing the cumulative peripheral sensory neuropathy (PSN) induced by the oxaliplatin (Ox) and 5-FU/LV combination (FOLFOX4) in first-line treatment of patients (pts) with metastatic colorectal cancer (MCRC)

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 3507-3507 ◽  
Author(s):  
J. Cassidy ◽  
G. A. Bjarnason ◽  
T. Hickish ◽  
C. Topham ◽  
M. Provencio ◽  
...  
Keyword(s):  
Cumulative Dose ◽  
Significant Risk ◽  
Dose Intensity ◽  
Sensory Neuropathy ◽  
Median Number ◽  
Phase Iii ◽  
First Line ◽  
Double Blind ◽  
Grade 3

3507 Background: X, an orally administered non-peptide neurotrophic agent developed by sanofi-aventis, was shown in vitro to minimize neuritic damage induced by Ox (co-culture of Schwann cells and dorsal roots ganglia explant). The probability of occurrence of Grade (Gr) 3–4 PSN at a cumulative dose of Ox of 1000 mg/m2, was consistently reported to be of 18–20%. Methods: First line MCRC pts were randomized to receive, in a DB fashion, FOLFOX4 and either Plcb or X 1mg daily. X was administered from the 1st day of chemotherapy till 15 days post last Ox cycle. Co-primary objectives were reduction in the risk of occurrence of Gr 3–4 PSN relative to cumulative dose of Ox (Kaplan-Meier method) and non-inferiority in response rate (RR). Secondary endpoints included evaluation of sensory action potential (SAP) and safety. Results: From July 2002 to May 2004, 649 pts were randomized (324 Plcb, 325 X). Pts characteristics were well balanced across arms, median number of Ox cycles was 12 in both arms, median relative dose intensity (%) was 83.8 (Plcb) and 85.2 (X). A significant risk reduction of 39% in the probability of Grade 3–4 PSN in favor of X was reported (hazard ratio [95% CI] = 0.61 [0.40; 0.93], p= 0.0203). Overall RR [95 % CI] was: Plcb 42.6% [37.1; 48.2] and X 44.9% [39.4; 50.6]. As prospectively defined in the protocol, the lower bound of the CI of the RR ratio above 0.8 confirms noninferiority in RR (1.055 [0.88; 1.26]). In both arms the mean % of change in SAP worsens as a function of PSN severity. 17.3 (Plcb) and 13.5% (X) of the pts discontinued Ox because of PSN. Severe toxicities (% Gr 3–4), reported with a ≥2% difference between arms, were (plcb vs X): diarrhea 10.9 vs 13.0, pulmonary embolism 0.9 vs 3.1, fatigue 3.7 vs 1.5, neutropenia 43.0 vs 37.8. Conclusion: X was shown to be efficient in reducing the risk of Grade 3–4 oxaliplatin-induced PSN without impacting FOLFOX4 antitumor activity. No significant financial relationships to disclose.

scholarly journals Randomized controlled trial of mibampator for behavioral and psychological symptoms of dementia: comments on the trial and thoughts for future studies

2013 ◽  
Vol 25 (5) ◽  
pp. 687-689 ◽  
Author(s):  
Clive Ballard ◽  
Paul Francis ◽  
Anne Corbett
Keyword(s):  
Psychological Symptoms ◽  
Controlled Trial ◽  
Treatment Options ◽  
Significant Risk ◽  
Good Evidence ◽  
Adverse Outcomes ◽  
Pharmacological Intervention ◽  
First Line ◽  
Long Term Treatment ◽  
Behavioral And Psychological Symptoms

Behavioral and psychological symptoms of dementia (BPSD) frequently arise in people with Alzheimer's disease (AD) and other dementias. They cause significant distress and confer risk to the person and others, in addition to presenting a complex clinical challenge for treatment (Ballard et al., 2009b). There is good evidence for the value of first-line management strategies such as psychological interventions and treatment of concurrent medical conditions, particularly pain, which are known to be effective (Ballard et al., 2009b). However, there are limited pharmacological treatment options for severe aggression, which causes significant risk, and for other severe BPSD which do not respond to first-line approaches. The only pharmacological intervention with an adequate evidence base is the prescription of atypical antipsychotics, where 18 placebo-controlled trials have evaluated the effect of treatment over 6–12 weeks. The literature indicates modest but significant benefits in the treatment of aggression and psychosis with risperidone and aripiprazole (Cohen's d standardized effect size of 0.2), uncertain benefits with olanzapine, and no benefits with quetiapine (Ballard and Howard, 2006; Schneider et al., 2006a; Ballard et al., 2009b; Corbett et al., 2012). Unfortunately, the benefits of longer term prescribing are more limited (Schneider et al., 2006b; Ballard et al., 2008) and there have been increasing concerns regarding the potential for serious adverse outcomes, including accelerated cognitive decline, stroke, and death (Schneider et al., 2006b; Ballard et al., 2009a). There is therefore an urgent imperative to identify more effective pharmacological treatments for severe BPSD which have a better safety profile, particularly for long-term treatment and prophylaxis. Despite this urgency, there has been very little effort toward developing or evaluating potential novel therapies for the treatment of key symptoms such as aggression, psychosis, restlessness, and apathy.

scholarly journals Metformin-Associated Lactic Acidosis following Intentional Overdose Successfully Treated with Tris-Hydroxymethyl Aminomethane and Renal Replacement Therapy

2012 ◽  
Vol 2012 ◽  
pp. 1-5 ◽  
Author(s):  
Ngan Lam ◽  
Gurbir Sekhon ◽  
Andrew A. House
Keyword(s):  
Metabolic Acidosis ◽  
Renal Replacement Therapy ◽  
Lactic Acidosis ◽  
Serum Creatinine ◽  
Replacement Therapy ◽  
Delayed Diagnosis ◽  
Complete Recovery ◽  
Nondiabetic Patient ◽  
Severe Metabolic Acidosis ◽  
Metformin Concentration

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.

Understanding violence: a qualitative study of violence and types of violence in neuropsychiatry practice

2011 ◽  
Vol 26 (S2) ◽  
pp. 776-776
Author(s):  
R. Faruqui ◽  
A. Tajer ◽  
B. Moffat
Keyword(s):  
Risk Assessment ◽  
Qualitative Analysis ◽  
Patient Population ◽  
Guideline Development ◽  
Sexual Offending ◽  
Significant Risk ◽  
Qualitative Evaluation ◽  
Service Planning ◽  
List Type ◽  
Management Service

IntroductionPatients with acquired brain injury and other neuropsychiatric conditions may present with a significant risk of violence.ObjectivesTo conduct a qualitative evaluation of violence to inform risk assessment, patient management, service planning, and workforce training in neuropsychiatryAimsTo provide thematic or qualitative categories based exploration of violence to enhance understanding of risk factors and risk presentations while clarifying the nature and types of violence in this patient population.MethodsA service evaluation exercise was conducted using routinely collected clinical information for patient group admitted at a neuropsychiatric service. Data files were converted in word format and transferred on qualitative analysis software NVIV0-8. This software was used for further qualitative analysis through creating free nodes in order to generate qualitative themes or categories of violence in this patient population.Results65 Male and 23 Female patients were admitted at the time of this review (working age adults). The qualitative data analysis using NVIVO-8 generated qualitative categories of violence in this patient population1.Violent Offending: Wounding, murder, criminal damage, sexual offending, arson2.Institutional violence: Directed towards patients and staff included, scratching, biting, slapping, punching, kicking, grabbing, groping.3.Sexual Violence: Stalking, rubbing, groping, exposing, masturbating, person directed sexual threats.4.Types of Violence: Impulsive violence, instrumental violence, grudges based violence, opportunistic violence, predatory violence, erotic violenceConclusionsQualitative categorisation of violence amongst a neuropsychiatric population is feasible and provides supportive evidence for further clinical practice and guideline development in violence risk assessment for this patient population.

Sign in / Sign up

Export Citation Format

Share Document