Metformin-associated lactic acidosis: Difference between revisions
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**Lactate only predictive of mortality in overdose patients, not in incidental metformin accumulation | **Lactate only predictive of mortality in overdose patients, not in incidental metformin accumulation | ||
**Elevated PT associated with increased mortality | **Elevated PT associated with increased mortality | ||
**pH > 6.9, lactate > 25 → 5 | **pH > 6.9, lactate > 25 → 5 out of 6 mortality in case series <ref>Dell'Aglio, D. M., Perino, L. J., Kazzi, Z., Abramson, J., Schwartz, M. D., & Morgan, B. W. (2009). Acute metformin overdose: examining serum pH, lactate level, and metformin concentrations in survivors versus nonsurvivors: a systematic review of the literature. Annals of emergency medicine, 6, 818–823.</ref> | ||
==Clinical Features== | ==Clinical Features== | ||
Revision as of 15:17, 17 October 2015
Background
- Acute and chronic use of metformin can lead to rare complication of Metformin-associate lactic acidosis (MALA)
- Excreted (unmetabolized) in proximal tubules
- Stimulates anaerobic glucose metabolism in splanchnic bed → increased lactate production
- Inhibits mitochondrial respiratory chain → decreased gluconeogensis from lactate → lactate accumulation
- Associated with overdose, renal failure, liver disease, acute infection as precipitants
- Acidosis onset several hours after acute ingestion
- Mortality rate 45% [1]
- Lactate only predictive of mortality in overdose patients, not in incidental metformin accumulation
- Elevated PT associated with increased mortality
- pH > 6.9, lactate > 25 → 5 out of 6 mortality in case series [2]
Clinical Features
- Nausea
- Vomiting
- Diarrhea
- Altered mental status
- Dyspnea
- Hypotension
- Tachycardia
- Tachypnea
Diagnosis
- FS
- [ASA]
- [APAP]
- EKG
- bHCG
- ABG
- Chem
- Lactate
Management
- If intubated, maintain minute ventilation so as to not remove respiratory compensation for acidosis
- Activated charcoal if peri-ingestion/AMS appropriate
- Metformin should not cause hypoglycemia and, if present, should lead to work up of cause
- Sodium Bicarbonate
- No evidence to support its use in MALA patients[3]
- Hemodialysis
- Metformin can be cleared with hemodialysis and CVVH (continuous venovenous hemofiltration)[4]
- Former preferred
- CVVH should be used in unstable patient
- Reduction in metformin levels following acute ingestion reported to require prolonged HD[5]
- Consider if:
- pH <7.1
- Renal insufficiency
- Mortality benefits mainly from improving acidosis than from removing Metformin
- Metformin can be cleared with hemodialysis and CVVH (continuous venovenous hemofiltration)[4]
References
- ↑ Seidowsky, A., Nseir, S., Houdret, N., & Fourrier, F. (2009). Metformin-associated lactic acidosis: a prognostic and therapeutic study. Critical care medicine, 7, 2191–2196.
- ↑ Dell'Aglio, D. M., Perino, L. J., Kazzi, Z., Abramson, J., Schwartz, M. D., & Morgan, B. W. (2009). Acute metformin overdose: examining serum pH, lactate level, and metformin concentrations in survivors versus nonsurvivors: a systematic review of the literature. Annals of emergency medicine, 6, 818–823.
- ↑ Kruse, J. A. (2001). Metformin-associated lactic acidosis. The Journal of emergency medicine, 3, 267–272.
- ↑ Barrueto, F., Meggs, W. J., & Barchman, M. J. (2002). Clearance of metformin by hemofiltration in overdose. Journal of toxicology. Clinical toxicology, 2, 177–180.
- ↑ Rifkin, S. I., McFarren, C., Juvvadi, R., & Weinstein, S. S. (2011). Prolonged hemodialysis for severe metformin intoxication. Renal failure, 4, 459–461.