The term metforminassociated lactic acidosis refers to any case of lactic acidosis that develops in a patient treated with metformin, with no further mechanistic insight. It has also been used as a prognostic index of mortality. Misbin ri, green l, stadel bv, gueriguian jl, gubbi a, fleming ga lactic acidosis in patients with diabetes treated with metformin. Lactic acidosis lactic acidosis is a rare, but serious complication that may occur due to metformin accumulation.
Metformininduced lactic acidosis with emphasis on the anion. Bicarbonate hemodialysis hd is recommended to decrease metformin levels and correct acidosis but its optimal duration has not been determined. In the intensive care setting lactate and ph levels are regularly used as a useful predictor of poor prognosis. In some cases, metformin can lead to a buildup of lactic acid in the blood referred to as lactic acidosis. Metformin is the first line management for patients with type 2 diabetes mellitus. However, your risk for developing lactic acidosis might be much higher, depending on whether you have other risk factors for lactic acidosis. Metformin, marketed under the trade name glucophage among others, is the firstline medication for the treatment of type 2 diabetes, particularly in people who are overweight. Aims lactic acidosis is a well recognized complication of biguanide therapy which is potentially serious. Metformininduced lactic acidosis mala is a severe side effect of metformin in high doses. Lactic acidosis is a rare, potentially fatal metabolic condition that can occur whenever substantial tissue hypoperfusion and hypoxia exist. We conducted a prospective observational study of metforminassociated aki cases during four years. However, although uncommon, lactic acidosis amongst diabetics can be fatal. However, there have not been many reported cases of mala. An unusual case of metformin associated lactic acidosisv poulose, fccp department ofmedicine, changi general hospital, 2 simei street 3, singapore 529889 introduction lactic acidosis is a wellknown, but rare complication ofbiguanide therapy.
Healthdayin a case report published in the october issue of clinical diabetes, lactic acidosis is described in a patient with normal renal function receiving metformin for type 2 diabetes. Study inclusion criteria were age older than 18 years, blood lactate higher than 10 mgdl and an initial diagnosis of septic shock icd9 codes 995. Metforminassociated lactic acidosis is a rare and serious complication of biguanide treatment. Acute and chronic use of metformin can lead to rare complication of metforminassociate lactic acidosis mala excreted unmetabolized in proximal tubules stimulates anaerobic glucose metabolism in splanchnic bed increased lactate production.
Analysis of the prognostic values of blood ph and lactate and plasma metformin concentrations in severe metformin associated lactic acidosis may help to resolve the following paradox. This study was designed to document the characteristics and prognostic factors of intentional and incidental metformin overdose and to determine the optimal duration of hd. Liraglutide can precipitate mala if taking metformin concomitantly as it often causes nausea and vomiting, which can lead. Lactic acidosis was detected in 69 4% out of 1,755 admitted patients, 44 were nondiabetic and 25 had diabetes mellitus, 11 of them treated with metformin. However, because of lack of data, the prognostic significance of hyperlactataemia in metformintreated patients is not known.
The lactic acidosis from metformin is primarily type b. Lactic acidosis is a common finding in critically ill patients admitted to the intensive care unit icu and it is associated with increased mortality 1, 2. Lactate is produced by the gut, liver, and peripheral tissues during glycolysis and can accumulate during hypoxic conditions. In real life, however, associated lactic acidosis has been repeatedly, although rarely, reported. We conducted a prospective observational study of metformin associated aki cases during four years. Are runners more likely to get lactic acidosis from taking.
Association of metformin use with risk of lactic acidosis. A high incidence of lactic acidosis was seen with phenformin therapy 4060100 000 patient. The liver, kidney, heart, and skeletal muscle are the primary lactate metabolizers, while. Natural history and course of acquired lactic acidosis in adults. First, this potential event still influences treatment strategies in type 2 diabetes mellitus, particularly in the many patients at risk of kidney failure, in those presenting contraindications to metformin and in the elderly. Populationbased studies have estimated a rate of 0. These conditions are associated with systemic hypoxemia, which may be caused by cardiorespiratory disease, major surgery, sepsis. Metformin is a safe drug when correctly used in properly selected patients. The high rate of severe lactic acidosis from phenformin led to the withdrawal of this drug from the us market in 1976, although it remains available in several countries. Lactic acidosis is described as a rare complication, usually during an acute kidney injury aki. In this article we highlight how high lactate levels are not an accurate predictor of mortality in deliberate metformin overdose. Lactic acidosis a buildup of lactic acid in the body is a rare complication of taking metformin glucophage, fortamet, but you could be at an increased risk for this condition if youre dehydrated or if you drink large amounts of alcohol. It is also used in the treatment of polycystic ovary syndrome.
We present a case of metforminassociated lactic acidosis mala where drug interactions orlistat in the long term and cimetidine over a short period of time may have potentiated. Risk of fatal and nonfatal lactic acidosis with metformin use. The incidence of lactic acidosis in patients on metformin therapy appears to be very low 4, 5, 6, but it can be fatal when it occurs. It usually occurs when a precipitating disease induces an acute renal failure and an incidental overdose. May 21, 2014 lactic acidosis is the most common cause of metabolic acidosis in hospitalized patients. No one left behind article pdf available in critical care london, england 151.
It was a rare entity but you explained well in short time. Rates of metformin associated lactic acidosis is about nine per 100,000 personyears, which is similar to the background rate of lactic acidosis in the general population. Runners who take the diabetes drug metformin glucophage, fortamet and become dehydrated may be at an increased risk of developing lactic acidosis. A rare case of persistent lactic acidosis in the icu. An unusual case of metformin associated lactic acidosis. Lactic acidosis is rare, but serious, with a mortality up to 50%. On the basis of 869 pharmacovigilance reports on mala with available data on arterial ph and lactate. Apr 21, 2008 l actic acidosis is an acute abnormal metabolic state associated with substantial mortality. Of 100,000 people, the incidence of lactic acidosis was 5. The authors concluded that metformin is not associated with an.
Metformin alone can lead to lactate buildup in your body, and alcohol has been shown to have this effect as well. A populationbased casecontrol study of lactic acidosis in 1,746 participants with type 2 diabetes and 846 individuals without diabetes with clinically measured lactates with and without aki between 19942014 was undertaken. Metforminassociated lactic acidosis is a rare but serious complication of biguanide treatment associated with high mortality. Lactic acidosis is a lifethreatening condition that is fatal in about 50 percent of cases and is caused by too much lactate in the blood and low blood ph. This condition, a buildup of lactic acid in the bloodstream, can be very serious even life threatening. Treatment of type b involves more specific management. Some investigators have attributed the association between metformin and lactic acidosis to the fact that type 2 diabetes is itself a risk factor for lactic acidosis, although this likely reflects the accompanying deterioration in other organ systems e. Lactic acidosis is the most common cause of metabolic acidosis in hospitalized patients.
Outcome of metforminassociated lactic acidosis in type 2. Metformin is the preferred oral antidiabetic agent for type 2 diabetes. Jan 21, 2011 the term metformin associated lactic acidosis refers to any case of lactic acidosis that develops in a patient treated with metformin, with no further mechanistic insight. The following describes a patient with acute renal failure and lactic acidosis as a result of concurrent treatment with metformin. Analysis of the prognostic values of blood ph and lactate and plasma metformin concentrations in severe metforminassociated lactic acidosis may help to resolve the following paradox. Facts about lactic acidosis correctly renamed lactate associated acidosis two clinical types type a decreased tissue oxygenation common e. The incidence of lactic acidosis in patients with type 2 diabetes is low but increases with age and duration of diabetes, as cardiovascular and renal causes become more prevalent. Metformin and lactic acidosis there are some potential adverse side effects of metformin. Lactic acidosis occurs when the blood turns acidic and there is a buildup of a chemical called lactate in your body.
A 58yrold female presented with a 4day history of increasing lethargy, anorexia, abdominal pain, and nausea. This utilised the genetics of diabetes audit and research tayside godarts cohort. The term metformininduced lactic acidosis refers to cases that cannot be explained by any major risk factor other than drug accumulation, usually due to renal failure. Nov 21, 2012 lactic acidosis associated with metformin treatment is a rare but important adverse event, and unravelling the problem is critical. The major toxic effect of metformin is lactic acidosis. Our results partially contradict a large cohort study investigating the association between metformin use and acidosis at low egfr. Am i likely to get lactic acidosis from taking metformin. Metformin is a commonly used treatment modality in type 2 diabetes mellitus, with a well documented side effect of lactic acidosis. What is the role of metformin in the etiology of lactic. Ten years retrospective analysis of patients admitted in intensive care unit for metformin associated lactic acidosis. The prognostic value of blood ph and lactate and metformin. Lactic acidosis almost never occurs with metformin exposure during routine medical care. Metforminassociated lactic acidosis presenting as an.
Metforminassociated acute kidney injury and lactic acidosis. It is important for physicians to measure metformin levels. L actic acidosis is an acute abnormal metabolic state associated with substantial mortality. The use of metformin is contraindicated in patients with renal dysfunction serum creatinine 1. Risk of fatal and nonfatal lactic acidosis with metformin. We present a case of lactic acidosis secondary to metformin therapy with associated ketosis from vomiting. Case of lactic acidosis with metformin, normal renal function. Lactic acidosis and severe septic shock in metformin users. The major toxicity from acute or chronic biguanide use is lactic acidosis. It is recognized as a potential complication of metformin use, particularly in patients with risk factors such as renal dysfunction, liver disease, and heavy alcohol ingestion. Results for metformin lactic acidosis 1 10 of 109 sorted by relevance date. Jan 15, 2016 the study comprised a cohort of patients diagnosed with septic shock and severe lactic acidosis. Lactic acidosis associated with metformin treatment is a rare but important adverse event, and unravelling the problem is critical.
Increased risk is associated with renal impairment, sepsis, dehydration, excess alcohol intake, hepatic impairment, and acute congestive heart failure. Treatment of type a lactic acidosis aims to improve perfusion and match oxygen consumption with oxygen delivery by giving fluids, packed red blood cells, and vasopressors or inotropic agents, or both. In most of the cases, however, lactic acidosis cannot be directly attributed to metformin use but rather depends on concomitant low cardiac output, anemia, hypoxemia or liver. In the majority of reported cases there is a preexisting disease, most often a degree of renal impairment. Irrespective of its underlying etiology, lactic acidosis is a life threatening condition characterized by low blood ph 5. Metformin induced lactic acidosis mala is a severe side effect of metformin in high doses. Increased use of metformin and lactic acidosis introduction. A rare but serious condition termed metforminassociated lactic acidosis mala can develop in patients with predisposing factors such as renal impairment, hepatic disease, congestive heart failure, or sepsis 8. What is the role of metformin in the etiology of lactic acidosis. Alcohol and metformin alcohol with metformin side effects. Previous renal function, clinical data, and outcomes. Metformin is the principal biguanide in clinical use. Lactic acidosis and high plasmatic metformin levels in a retrospective case series of 66 patients on chronic therapy article pdf available in clinical toxicology 522. Elevated plasma metformin concentrations as occur in individuals with renal impairment and a secondary event or condition that further disrupts lactate production or clearance e.
Case was a 70yearold man with metformin associated lactic acidosis mala. So, i have had borderline blood sugar for a long time. We conducted a retrospective analysis of patients admitted in icu with mala during a fiveyear period. Rarely, a serious condition called metforminassociated lactic acidosis mala can occur in patients with predisposing factors such as renal insufficiency, hepatic disease, congestive heart failure, or sepsis. Metformininduced lactic acidosis with emphasis on the. Data were collected from 49 metformintreated patients with lactic acidosis arterial lactate level. Metformin and lactic acidosis in an australian community. It is a type of high anion gap metabolic acidosis and is associated with various pathological processes. Treatment consists of vital function support and drug. Stacpoole pw, wright ec, baumgartner tg, bersin rm, buchalter s, curry sh, et al. Metforminassociated lactic acidosis can occur acutely in an overdose but typically has a more gradual onset in patients with hepatic or renal dysfunction due to decreased excretion. Increased use of metformin and lactic acidosis introduction metformin e.
Oct 31, 2007 the occurrence of metformin induced lactic acidosis is exceptional when the drug is used with caution. Pdf lactic acidosis induced by metformin incidence. Therefore, the combination of alcohol and metformin together may be even more dangerous than either one alone. It often presents with nausea, abdominal pain, tachycardia, hypotension, and tachypnea. The term metformin induced lactic acidosis refers to cases that cannot be explained by any major risk factor other than drug accumulation, usually due to renal failure. Click export csv or ris to download the entire page or use the checkboxes to select a subset of records to download.
Metformin associated lactic acidosis sunghwan suh division of endocrinology and metabolism, department of internal medicine, donga medical center, donga university college of medicine, busan, korea metformin has been used in europe since the 1970s to treat type 2 diabetes mellitus t2dm. But metformin has never been clearly been implicated in lactic acidosis taken from the incidence of lactic. Kim and colleagues 9 investigated the clinical profiles of. Since february 1999 according to the practice guidelines of the dutch college of general practitioners 1, metformin is the drug of first choice for the treatment of obese patients with. The occurrence of metformin induced lactic acidosis is exceptional when the drug is used with caution. Metformin lactic acidosis, acute renal failure and rofecoxib. Lactic acidosis is a rare 1 but serious complication of metformin therapy with a high fatality rate 2. The premorbid conditions, clinical presentations, biological data, therapeutic strategies and outcomes were recorded. The threshold metformin concentration needed to induce lactic acidosis is still not fully understood. This side effect is rare, affecting about one in every 30,000 metformin patients.
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