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Tomoda Y, Kobayashi M. An in vitro study of metformin adsorption to activated charcoal. Clin Toxicol (Phila) 2024; 62:237-241. [PMID: 38646866 DOI: 10.1080/15563650.2024.2338556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/29/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION Metformin is a biguanide used to manage patients with type 2 diabetes mellitus. However, metabolic acidosis with an elevated lactate concentration and death caused by metformin overdoses are toxicological concerns. Although activated charcoal has been widely used for gastrointestinal decontamination in cases of acute poisoning, there is no evidence regarding its efficacy in treating metformin overdoses. We therefore evaluated the adsorptive capacity of activated charcoal for metformin in vitro. METHODS Activated charcoal (specific surface area: 1,080 m2/g) mixed with various concentrations of metformin solution was dissolved in simulated gastric and intestinal fluids at 37° Celsius. The suspension was then filtered and the metformin concentration in the filtrate was determined using high-performance liquid chromatography. The maximum adsorptive capacity for metformin was calculated using the Langmuir adsorption isotherm equation. RESULTS The amount of metformin adsorbed per gram of activated charcoal ranged from 0.7 to 8.1 mg/g at pH 1.2, and from 8.4 to 48.2 mg/g at pH 6.8. The corresponding maximum adsorptive capacities were 10.6 mg/g and 55.9 mg/g respectively. DISCUSSION The maximum adsorptive capacity of activated charcoal for metformin was similar to that of its capacity for other poorly adsorbed substances. This is likely because metformin is water-soluble and has high polarity-factors that correlate with poor adsorption on activated charcoal. CONCLUSIONS The maximum adsorption of metformin by activated charcoal was low. Therefore, activated charcoal may not be effective for treating patients with metformin overdose.
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Affiliation(s)
- Yoshinori Tomoda
- Laboratory of Clinical Pharmacokinetics, Research and Education Center for Clinical Pharmacy, Kitasato University School of Pharmacy, Tokyo, Japan
| | - Masahiro Kobayashi
- Laboratory of Clinical Pharmacokinetics, Research and Education Center for Clinical Pharmacy, Kitasato University School of Pharmacy, Tokyo, Japan
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2
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Du Y, Zhu J, Guo Z, Wang Z, Wang Y, Hu M, Zhang L, Yang Y, Wang J, Huang Y, Huang P, Chen M, Chen B, Yang C. Metformin adverse event profile: a pharmacovigilance study based on the FDA Adverse Event Reporting System (FAERS) from 2004 to 2022. Expert Rev Clin Pharmacol 2024; 17:189-201. [PMID: 38269492 DOI: 10.1080/17512433.2024.2306223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Metformin has the potential for treating numerous diseases, but there are still many unrecognized and unreported adverse events (AEs). METHODS We selected data from the United States FDA Adverse Event Reporting System (FAERS) database from the first quarter (Q1) of 2004 to the fourth quarter (Q4) of 2022 for disproportionality analysis to assess the association between metformin and related adverse events. RESULTS In this study 10,500,295 case reports were collected from the FAERS database, of which 56,674 adverse events related to metformin were reported. A total of 643 preferred terms (PTs) and 27 system organ classes (SOCs) that were significant disproportionality conforming to the four algorithms simultaneously were included. The SOCs included metabolic and nutritional disorders (p = 0.00E + 00), gastrointestinal disorders (p = 0.00E + 00) and others. PT levels were screened for adverse drug reaction (ADR) signals such as acute pancreatitis (p = 0.00E + 00), melas syndrome, pemphigoid (p = 0.00E + 00), skin eruption (p = 0.00E + 00) and drug exposure during pregnancy (p = 0.00E + 00). CONCLUSION Most of our results were consistent with the specification, but some new signals of adverse reactions such as acute pancreatitis were not included. Therefore, further studies are needed to validate unlabeled adverse reactions and provide important support for clinical monitoring and risk identification of metformin.
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Affiliation(s)
- Yikuan Du
- Central Laboratory, The Tenth Affiliated Hospital of Southern Medical University, Dongguan, People's Republic of China
| | - Jinfeng Zhu
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Zhuoming Guo
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Zhenjie Wang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Yuni Wang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Mianda Hu
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Lingzhi Zhang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Yurong Yang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Jinjin Wang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Yixing Huang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Peiying Huang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Mianhai Chen
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Bo Chen
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
| | - Chun Yang
- Dongguan Key Laboratory of Stem Cell and Regenerative Tissue Engineering, The First Dongguan Affiliated Hospital, School of Basic Medical Sciences, Guangdong Medical University, Dongguan, China
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3
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Sarah EH, El Omri N, Ibrahimi A, El Jaoudi R. Metabolic and genetic studies of glimepiride and metformin and their association with type 2 diabetes. GENE REPORTS 2020. [DOI: 10.1016/j.genrep.2020.100787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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4
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Theobald J, Schneider J, Cheema N, DesLauriers C. Time to development of metformin-associated lactic acidosis. Clin Toxicol (Phila) 2019; 58:758-762. [PMID: 31691608 DOI: 10.1080/15563650.2019.1686514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Metformin-associated lactic acidosis (MALA) is a complication of metformin overdose. Recommendations for observation time after an acute ingestion to monitor for MALA vary. The aim of this study was to characterize the time to development of MALA after an acute metformin overdose.Methods: Utilizing Crystal Reports (Version 11.0), all metformin cases reported to the Illinois Poison Center (IPC) with a National Poison Data System (NPDS) clinical effects code of "acidosis" or "anion gap" were retrospectively queried over a 14-year period (2001-2014). Demographic data, time to MALA, co-ingestants, therapeutic modality use, and case outcome were extracted. Interrater reliability was assessed using kappa analysis.Results: A total of 88 cases were identified of which 44 met criteria for MALA; 40 were acute, acute on chronic, or unknown ingestions. The remaining four were chronic ingestions which were excluded. The mean age was 41 years (range 19-79 years). Most were female (55.0%) and over half (62.5%) were acute on chronic ingestions. Hypoglycemia was seen in three ingestions of metformin only. Of the 40 MALA cases, 18 developed MALA less than or equal to 6 h after ingestion, 9 between 6-12 h, 3 after 12 h, and 10 patients had an unknown time to MALA. The only death in the cohort had MALA detected beyond the typical 6-h observation period. Of the exposures when time to MALA was known, 40% (12/30) developed MALA greater than 6 h post ingestion.Conclusion: A 6-h observation period after a single acute ingestion of metformin may be inadequate, as a significant portion of exposures developed MALA beyond this time. We recommend a minimum of 12 h of observation following an acute overdose. Further study defining prospectively the time to development of MALA may improve management of this population.
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Affiliation(s)
- Jillian Theobald
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Wisconsin Poison Center, Milwaukee, WI, USA
| | - Jamie Schneider
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Navneet Cheema
- Department of Medicine, Section of Emergency Medicine, University of Chicago, Chicago, IL, USA
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5
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Simon M, Baudry T, Hernu R, Cour M, Argaud L. Intoxication à la metformine. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La metformine, seul représentant disponible en France de la classe des biguanides, est un médicament antidiabétique largement prescrit. L’effet thérapeutique bénéfique du contrôle glycémique obtenu par inhibition de la néoglucogenèse est objectivé par une réduction de la morbimortalité chez les patients diabétiques de type 2. Néanmoins, la metformine affecte aussi le métabolisme du lactate en augmentant sa production par la cellule. Ainsi, l’effet secondaire le plus redouté est l’acidose lactique associée à la metformine (metformin-associated lactic acidosis [MALA]). Celle-ci est liée à une augmentation brutale de la concentration en metformine dans le sang et dans les tissus, que ce soit après ingestion d’une grande quantité de médicament ou plus souvent dans les suites d’une insuffisance rénale aiguë chez un patient traité au long cours. Dans ce contexte d’acidose métabolique majeure avec hyperlactatémie, la sévérité des défaillances d’organes conditionne le pronostic. La prise en charge thérapeutique est symptomatique avec recours précoce à une épuration extrarénale dans les formes sévères ou ne répondant pas au traitement initial. La prévention de la MALA repose avant tout sur le respect des contreindications de la metformine chez les patients diabétiques.
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6
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Corchia A, Wynckel A, Journet J, Moussi Frances J, Skandrani N, Lautrette A, Zafrani L, Lewandowski E, Reboul P, Vrigneaud L, Djerada Z, Rieu P. Metformin-related lactic acidosis with acute kidney injury: results of a French observational multicenter study. Clin Toxicol (Phila) 2019; 58:375-382. [DOI: 10.1080/15563650.2019.1648816] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Julien Journet
- Department of Nephrology, William Morey Hospital, Chalon-sur-Saône, France
| | - Julie Moussi Frances
- Department of Nephrology, APHM Hôpital de la Conception, CHU Marseille, Marseille, France
| | - Nihel Skandrani
- Department of Nephrology, Belfort Montbéliard Hospital, Montbéliard, France
| | | | - Lara Zafrani
- Intensive Care Unit, Hôpital Saint Louis, Paris, France
| | | | | | - Laurence Vrigneaud
- Department of Internal Medicine & Nephrology, Valenciennes Hospital, Valenciennes, France
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7
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Stevens A, Hamel J, Toure A, Hadjadj S, Boels D. Metformin overdose: A serious iatrogenic complication—Western France Poison Control Centre Data Analysis. Basic Clin Pharmacol Toxicol 2019; 125:466-473. [DOI: 10.1111/bcpt.13273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/06/2019] [Indexed: 12/31/2022]
Affiliation(s)
| | - Jean‐François Hamel
- Representative of Clinical Research and Innovation Angers University Hospital Angers France
| | - Ali Toure
- Poison Control Centre Angers University Hospital Angers France
| | - Samy Hadjadj
- Department of Endocrinology and Diabetology Nantes University Hospital Nantes France
| | - David Boels
- Poison Control Centre Angers University Hospital Angers France
- Department of Pharmacology and Toxicology Nantes University Hospital Nantes France
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8
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Sajib AA, Islam T, Paul N, Yeasmin S. Interaction of rs316019 variants of SLC22A2 with metformin and other drugs- an in silico analysis. J Genet Eng Biotechnol 2018; 16:769-775. [PMID: 30733798 PMCID: PMC6353654 DOI: 10.1016/j.jgeb.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/16/2018] [Indexed: 02/08/2023]
Abstract
Metformin is one of the first-line and most widely prescribed drugs to treat type 2 diabetes (T2D). Its clearance from circulation is mostly facilitated by SLC22A2 (OCT2) in the renal cells. SLC22A2 is a polyspecific organic cation transporter and mediate transport of structurally unrelated endogenous and exogenous compounds including many drugs. rs316019 (p.270A > S) is the most common variant of SLC22A2 with a frequency as high as 15% or more in many populations. The 270S form of SLC22A2 clears metformin from circulation at much reduced level compared to the 270A form. If accumulated, metformin increases plasma lactate level in a concentration-dependent manner which can lead to a condition known as metformin-associated lactic acidosis (MALA). MALA is a potentially life-threatening complication with a mortality rate of 30-50%. Pre-existing clinical conditions, such as renal impairment, sepsis, anoxia, etc may make individuals more prone to MALA. In this study, we used computational approaches to investigate the effect of 270A > S change in SLC22A2 on interaction with metformin and other drugs. Based on the structural models, all substrates bind to the same pocket of SLC22A2. The substrates fit better to the binding site of 270A form of SLC22A2. The binding site has a few core interacting residues, among which SER358 appears to be the most important. It is an in silico prediction that the T2D patients, who are under metformin regimen, should be cautious in taking ranitidine (an over-the-counter sold drug) on a regular basis as it may lead to metformin associated lactate accumulation in blood.
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Affiliation(s)
- Abu Ashfaqur Sajib
- Department of Genetic Engineering and Biotechnology, University of Dhaka, Dhaka 1000, Bangladesh
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9
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Suzuki K, Okada H, Yoshida S, Okamoto H, Suzuki A, Suzuki K, Yamada Y, Hayashi H, Yasuda R, Fukuta T, Kitagawa Y, Miyake T, Kawaguchi T, Watanabe T, Doi T, Kumada K, Ushikoshi H, Sugiyama T, Itoh Y, Ogura S. Effect of high-flow high-volume-intermittent hemodiafiltration on metformin-associated lactic acidosis with circulatory failure: a case report. J Med Case Rep 2018; 12:280. [PMID: 30266098 PMCID: PMC6162950 DOI: 10.1186/s13256-018-1809-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/20/2018] [Indexed: 01/07/2023] Open
Abstract
Background Metformin-associated lactic acidosis is a well-known life-threatening complication of metformin. We here report the case of a patient who developed metformin-associated lactic acidosis without organ manifestations, due to the simultaneous ingestion of an overdose of metformin and alcohol, and who recovered with high-flow high-volume intermittent hemodiafiltration. Case presentation A 44-year-old Asian woman with type 2 diabetes attempted suicide by ingesting 10 tablets of metformin 500 mg and drinking approximately 600 mL of Japanese sake containing 15% alcohol. She was transferred to our emergency department because of disturbed consciousness. Continuous intravenous administration of noradrenalin (0.13 μg/kg per minute) was given because she was in shock. Laboratory findings included a lactate level of 119 mg/dL (13.2 mmol/L), bicarbonate of 14.5 mmol/L, and serum metformin concentration of 1138 ng/mL. She was diagnosed as having metformin-associated lactic acidosis worsened by alcohol. After 4560 mL of bicarbonate ringer (Na+ 135 mEq/L, K+ 4 mEq/L, Cl− 113 mEq/L, HCO3− 25 mEq/L) was administered, high-flow high-volume intermittent hemodiafiltration. (dialysate flow rate: 500 mL/min, substitution flow rate: 3.6 L/h) was carried out for 6 h to treat metabolic acidosis and remove lactic acid and metformin. Consequently, serum metformin concentration decreased to 136 ng/mL and noradrenalin administration became unnecessary to maintain normal vital signs. On hospital day 12, she was moved to the psychiatry ward. Conclusions HFHV-iHDF may be able to remove metformin and lactic acid efficiently and may improve the condition of hemodynamically unstable patients with metformin-associated lactic acidosis.
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Affiliation(s)
- Kodai Suzuki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Haruka Okamoto
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Keiko Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Yuto Yamada
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Hideki Hayashi
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, Japan.,Community Healthcare Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Ryu Yasuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tetsuya Fukuta
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Yuichiro Kitagawa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takahito Miyake
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tomonori Kawaguchi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takatomo Watanabe
- Division of Clinical Laboratory, Gifu University Hospital, Gifu, Japan
| | - Tomoaki Doi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Keisuke Kumada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Hiroaki Ushikoshi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tadashi Sugiyama
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, Japan.,Community Healthcare Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Yoshinori Itoh
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
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Krauzová E, Tůma P, de Glisezinski I, Štich V, Šiklová M. Metformin Does Not Inhibit Exercise-Induced Lipolysis in Adipose Tissue in Young Healthy Lean Men. Front Physiol 2018; 9:604. [PMID: 29875699 PMCID: PMC5974160 DOI: 10.3389/fphys.2018.00604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/04/2018] [Indexed: 01/04/2023] Open
Abstract
Objective: Metformin was shown to exert an antilipolytic action in adipose tissue (AT) that might mediate beneficial effects on lipid metabolism in diabetic patients. However, during exercise, the inhibition of induced lipolysis in AT would limit the energy substrate supply for working muscle. Thus, the aim of this study was to investigate whether metformin exerts inhibitory effect on exercise-induced lipolysis in subcutaneous adipose tissue (SCAT) (Moro et al., 2007) in humans. Approach: Ten healthy lean men underwent two exercise sessions consisting of 60 min of cycling on bicycle ergometer combined with (a) orally administered metformin and (b) metformin locally administered into SCAT. Microdialysis was used to assess lipolysis in situ in SCAT. Glycerol, metformin and lactate were measured in dialysate and plasma by enzyme colorimetric kits and capillary electrophoresis. Results: Metformin levels increased continuously in plasma during 3 h after oral administration, and peaked after 3.5 h (peak concentration 4 μg/ml). Metformin was detected in dialysate outflowing from SCAT and showed a similar time-course as that in plasma with the peak concentration of 1.3 μg/ml. The lipolytic rate in SCAT (assessed as glycerol release) increased in response to exercise (4.3 ± 0.5-fold vs. basal; p = 0.002) and was not suppressed either by local or oral metformin administration. The lactate levels increased in plasma and in dialysate from SCAT after 30-60 min of exercise (3.6-fold vs. basal; p = 0.015; 2.75-fold vs. basal; p = 0.002, respectively). No effect of metformin on lactate levels in SCAT dialysate or in plasma during exercise was observed. Conclusion: Metformin did not reduce the exercise-induced lipolysis in SCAT. This suggests that metformin administration does not interfere with the lipid mobilization and energy substrate provision during physical activity.
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Affiliation(s)
- Eva Krauzová
- Department for the Study of Obesity and Diabetes, Third Faculty of Medicine, Charles University, Prague, Czechia.,Second Department of Internal Medicine, University Hospital Královské Vinohrady, Prague, Czechia
| | - Petr Tůma
- Department of Hygiene, Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Isabelle de Glisezinski
- INSERM, UMR1048, Obesity Research Laboratory, Institute of Metabolic and Cardiovascular Diseases, University of Toulouse, Paul Sabatier University, Toulouse, France.,Department of Clinical Biochemistry and Sports Medicine, Toulouse University Hospital, Toulouse, France
| | - Vladimír Štich
- Department for the Study of Obesity and Diabetes, Third Faculty of Medicine, Charles University, Prague, Czechia.,Second Department of Internal Medicine, University Hospital Královské Vinohrady, Prague, Czechia
| | - Michaela Šiklová
- Department for the Study of Obesity and Diabetes, Third Faculty of Medicine, Charles University, Prague, Czechia
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11
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Ueda Y, Wong C, Borchers A. Severe lactic acidosis and hypoglycemia due to acute metformin intoxication in a dog. J Vet Emerg Crit Care (San Antonio) 2018; 28:274-278. [PMID: 29687945 DOI: 10.1111/vec.12711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 08/26/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report a case of severe lactic acidosis and hypoglycemia due to acute metformin intoxication in a dog. CASE SUMMARY A female neutered Rat Terrier was presented for an acute onset of seizure-like episodes, weakness, and vomiting approximately 14 hours after ingestion of 198 mg/kg of metformin. The dog was found to be laterally recumbent, paddling, and unresponsive shortly before presentation. On physical exam, the dog was in hypovolemic shock and hypothermic. Blood work revealed severe lactic acidosis and hypoglycemia. The dog was volume resuscitated with intravenous crystalloids and dextrose, followed by a continuous infusion of intravenous fluids and dextrose, as well as administration of isotonic sodium bicarbonate. Repeat blood work showed minimal improvement of the hyperlactatemia for 3 hours despite resolution of hypovolemia and hypoglycemia followed by gradual improvement over the next 9 hours of hospitalization. High performance liquid chromatography/tandem mass spectrometry analysis showed markedly increased plasma metformin concentrations at 3.9 μg/mL. The dog was discharged from the hospital within 24 hours and showed no recurrence of clinical signs one year following discharge. NEW OR UNIQUE INFORMATION PROVIDED Metformin-associated lactic acidosis and hypoglycemia is a severe complication in human patients, but has not been reported in veterinary medicine. Aggressive treatment with supportive care including IV fluids and dextrose administration resulted in resolution of the clinical signs in this patient. Metformin toxicosis should be considered in dogs with severe hyperlactatemia and hypoglycemia of unknown etiology.
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Affiliation(s)
- Yu Ueda
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, 95616
| | - Christine Wong
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, 95616
| | - Angela Borchers
- William R. Pritchard Veterinary Medical Teaching Hospital, University of California, Davis, Davis, CA, 95616
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Lalau JD, Kajbaf F, Bennis Y, Hurtel-Lemaire AS, Belpaire F, De Broe ME. Metformin Treatment in Patients With Type 2 Diabetes and Chronic Kidney Disease Stages 3A, 3B, or 4. Diabetes Care 2018; 41:547-553. [PMID: 29305402 DOI: 10.2337/dc17-2231] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/11/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study was conducted to define a safe, effective dose regimen for metformin in moderate and severe chronic kidney disease (CKD; stages 3A/3B and 4, respectively), after the lifting of restrictions on metformin use in patients with diabetes with moderate-to-severe CKD in the absence of prospective safety and efficacy studies. RESEARCH DESIGN AND METHODS Three complementary studies were performed: 1) a dose-finding study in CKD stages 1-5, in which blood metformin concentrations were evaluated during a 1-week period after each dose increase; 2) a 4-month metformin treatment study for validating the optimal metformin dose as a function of the CKD stage (3A, 3B, and 4), with blood metformin, lactate, and HbA1c concentrations monitored monthly; and 3) an assessment of pharmacokinetic parameters after the administration of a single dose of metformin in steady-state CKD stages 3A, 3B, and 4. RESULTS First, in the dose-finding study, the appropriate daily dosing schedules were 1,500 mg (0.5 g in the morning [qam] +1 g in the evening [qpm]) in CKD stage 3A, 1,000 mg (0.5 g qam + 0.5 g qpm) in CKD stage 3B, and 500 mg (qam) in CKD stage 4. Second, after 4 months on these regimens, patients displayed stable metformin concentrations that never exceeded the generally accepted safe upper limit of 5.0 mg/L. Hyperlactatemia (>5 mmol/L) was absent (except in a patient with myocardial infarction), and HbA1c levels did not change. Third, there were no significant differences in pharmacokinetic parameters among the CKD stage groups. CONCLUSIONS Provided that the dose is adjusted for renal function, metformin treatment appears to be safe and still pharmacologically efficacious in moderate-to-severe CKD.
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Affiliation(s)
- Jean-Daniel Lalau
- Department of Endocrinology-Nutrition, Amiens University Medical Center, Amiens, France .,INSERM 1088, Université de Picardie Jules Verne, Amiens, France
| | - Farshad Kajbaf
- Department of Endocrinology-Nutrition, Amiens University Medical Center, Amiens, France.,INSERM 1088, Université de Picardie Jules Verne, Amiens, France
| | - Youssef Bennis
- Laboratoire de Pharmacologie Clinique, Amiens University Medical Center, Amiens, France
| | | | - Frans Belpaire
- Heymans Institute of Pharmacology, University of Ghent, Ghent, Belgium
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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13
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Lalau JD, Kajbaf F, Protti A, Christensen MM, De Broe ME, Wiernsperger N. Metformin-associated lactic acidosis (MALA): Moving towards a new paradigm. Diabetes Obes Metab 2017; 19:1502-1512. [PMID: 28417525 DOI: 10.1111/dom.12974] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/03/2017] [Accepted: 04/11/2017] [Indexed: 12/15/2022]
Abstract
Although metformin has been used for over 60 years, the balance between the drug's beneficial and adverse effects is still subject to debate. Following an analysis of how cases of so-called "metformin-associated lactic acidosis" (MALA) are reported in the literature, the present article reviews the pitfalls to be avoided when assessing the purported association between metformin and lactic acidosis. By starting from pathophysiological considerations, we propose a new paradigm for lactic acidosis in metformin-treated patients. Metformin therapy does not necessarily induce metformin accumulation, just as metformin accumulation does not necessarily induce hyperlactatemia, and hyperlactatemia does not necessarily induce lactic acidosis. In contrast to the conventional view, MALA probably accounts for a smaller proportion of cases than either metformin-unrelated lactic acidosis or metformin-induced lactic acidosis. Lastly, this review highlights the need for substantial improvements in the reporting of cases of lactic acidosis in metformin-treated patients. Accordingly, we propose a check-list as a guide to clinical practice.
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Affiliation(s)
- Jean-Daniel Lalau
- Department of Endocrinology-Nutrition, Amiens University Hospital, Amiens, France
| | - Farshad Kajbaf
- Department of Endocrinology-Nutrition, Amiens University Hospital, Amiens, France
| | - Alessandro Protti
- Department of Anesthesia and Intensive Care, IRCCS Fondazione Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - Mette M Christensen
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Marc E De Broe
- Laboratory of Pathophysiology, University of Antwerp, Wilrijk, Belgium
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Cucchiari D, Podestà MA, Merizzoli E, Calvetta A, Morenghi E, Angelini C, Ponticelli C, Badalamenti S. Dose-related effects of metformin on acid-base balance and renal function in patients with diabetes who develop acute renal failure: a cross-sectional study. Acta Diabetol 2016; 53:551-8. [PMID: 26821225 DOI: 10.1007/s00592-016-0836-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 01/01/2016] [Indexed: 12/21/2022]
Abstract
AIMS The role of metformin in the development of lactic acidosis (LA) in the setting of acute renal failure (ARF) is debated. Moreover, recent experiments suggested that metformin can also be nephrotoxic, but little clinical data exist about this topic. We sought to investigate these possible associations in a large cohort of patients with diabetes who developed ARF. METHODS We analyzed data from patients with diabetes admitted to our emergency department between 2007 and 2011 with ARF and a previously normal renal function (n = 126). We compared acid-base balance and renal function of patients taking metformin (n = 74) with patients not taking it (n = 52). RESULTS Patients taking metformin had decreased pH (7.31 ± 0.16 vs 7.39 ± 0.11, p = 0.008) and higher lactates (4.54 ± 4.30 vs 1.71 ± 1.14 mmol/L, p < 0.001). Both acidosis (pH < 7.35) and LA (lactates >5 mmol/L and pH < 7.35) were more frequently observed in this group (p = 0.0491 and p < 0.001, respectively). Multivariate analysis ruled out the role of some possible confounders, especially decreased renal function. The influence of metformin on pH and lactates grew significantly with higher doses of the drug (p = 0.259 and p = 0.092 for <1 g/day, p = 0.289 and p < 0.001 for 1-2 g/day, p = 0.009 and p < 0.001 for 2-3 g/day, for pH and lactates, respectively). Metformin influenced creatinine levels in a dose-related manner as well (p = 0.925 for <1 g/day, p = 0.033 for 1-2 g/day, p < 0.001 for 2-3 g/day). CONCLUSIONS In patients with diabetes who were admitted to our emergency department with ARF, the use of metformin was associated in a dose-related fashion with both LA and worse renal function.
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Affiliation(s)
- David Cucchiari
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy.
| | - Manuel Alfredo Podestà
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Elisa Merizzoli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Albania Calvetta
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Emanuela Morenghi
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Claudio Angelini
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Claudio Ponticelli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Salvatore Badalamenti
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, MI, Italy
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15
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Case Files from the University of California San Diego Health System Fellowship Coma and Severe Acidosis: Remember to Consider Acetaminophen. J Med Toxicol 2016; 11:368-76. [PMID: 26153488 DOI: 10.1007/s13181-015-0492-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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16
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Brinkmann C, Brixius K. Hyperlactatemia in type 2 diabetes: Can physical training help? J Diabetes Complications 2015; 29:965-9. [PMID: 26122286 DOI: 10.1016/j.jdiacomp.2015.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 05/15/2015] [Accepted: 05/16/2015] [Indexed: 01/11/2023]
Abstract
Type 2 diabetic patients often exhibit hyperlactatemia in association with a reduced aerobic-oxidative capacity and a restricted lactate transport. Studies suggest a link between increased lactate levels and the manifestation and progression of insulin resistance. However, the specificities of molecular mechanisms remain unclear, and it is not entirely clear whether elevated lactate levels are a cause or consequence of type 2 diabetes. This review focuses on lactate as a key molecule in diabetes and provides an overview of how regular physical activity can be helpful in normalizing elevated lactate levels in type 2 diabetic patients. Physical training may reduce lactate production and reinforce lactate transport and clearance among this particular patient group. We emphasize the crucial role physical training plays in the therapy of type 2 diabetes due to evidence that pharmacological treatment with metformin, which is commonly used in the first-line therapy of type 2 diabetes, does not help reducing lactate levels.
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Affiliation(s)
- Christian Brinkmann
- Institute of Cardiovascular Research and Sport Medicine, Department of Molecular and Cellular Sport Medicine, German Sport University Cologne, Cologne, Germany.
| | - Klara Brixius
- Institute of Cardiovascular Research and Sport Medicine, Department of Molecular and Cellular Sport Medicine, German Sport University Cologne, Cologne, Germany
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17
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McNamara K, Isbister GK. Hyperlactataemia and clinical severity of acute metformin overdose. Intern Med J 2015; 45:402-8. [DOI: 10.1111/imj.12713] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/02/2015] [Indexed: 11/29/2022]
Affiliation(s)
- K. McNamara
- Department of Clinical Toxicology and Pharmacology; Calvary Mater Newcastle; Newcastle New South Wales Australia
| | - G. K. Isbister
- Department of Clinical Toxicology and Pharmacology; Calvary Mater Newcastle; Newcastle New South Wales Australia
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
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Grün B, Kiessling MK, Burhenne J, Riedel KD, Weiss J, Rauch G, Haefeli WE, Czock D. Trimethoprim-metformin interaction and its genetic modulation by OCT2 and MATE1 transporters. Br J Clin Pharmacol 2014; 76:787-96. [PMID: 23305245 DOI: 10.1111/bcp.12079] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 12/22/2012] [Indexed: 12/11/2022] Open
Abstract
AIMS Metformin pharmacokinetics depends on the presence and activity of membrane-bound drug transporters and may be affected by transport inhibitors. The aim of this study was to investigate the effects of trimethoprim on metformin pharmacokinetics and genetic modulation by organic cation transporter 2 (OCT2) and multidrug and toxin extrusion 1 (MATE1) polymorphisms. METHODS Twenty-four healthy volunteers received metformin 500 mg three times daily for 10 days and trimethoprim 200 mg twice daily from day 5 to 10. Effects of trimethoprim on steady-state metformin pharmacokinetics were analysed. RESULTS In the population as a whole, trimethoprim significantly reduced the apparent systemic metformin clearance (CL/F) from 74 to 54 l h(-1) and renal metformin clearance from 31 to 21 l h(-1) , and prolonged half-life from 2.7 to 3.6 h (all P < 0.01). This resulted in an increase in the maximal plasma concentration by 38% and in the area under the plasma concentration-time curve by 37%. In volunteers polymorphic for both OCT2 and MATE1, trimethoprim had no relevant inhibitory effects on metformin kinetics. Trimethoprim was associated with a decrease in creatinine clearance from 133 to 106 ml min(-1) (P < 0.01) and an increase in plasma lactate from 0.94 to 1.2 mmol l(-1) (P = 0.016). CONCLUSIONS The extent of inhibition by trimethoprim was moderate, but might be clinically relevant in patients with borderline renal function or high-dose metformin.
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Affiliation(s)
- Barbara Grün
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
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Abstract
Metformin is the most commonly prescribed medication for type 2 diabetes (T2DM) in the world. It has primacy in the treatment of this disease because of its safety record and also because of evidence for reduction in the risk of cardiovascular events. Evidence has accumulated indicating that metformin is safe in people with stage 3 chronic kidney disease (CKD-3). It is estimated that roughly one-quarter of people with CKD-3 and T2DM in the United States (well over 1 million) are ineligible for metformin treatment because of elevated serum creatinine levels. This could be overcome if a scheme, perhaps based on pharmacokinetic studies, could be developed to prescribe reduced doses of metformin in these individuals. There is also substantial evidence from epidemiologic studies to indicate that metformin may not only be safe, but may actually benefit people with heart failure (HF). Prospective, randomized trials of the use of metformin in HF are needed to investigate this possibility.
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Affiliation(s)
- John M. Miles
- To whom correspondence should be addressed. Telephone 507 284 3289; Fax 507 255 4828
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20
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Bonsignore A, Pozzi F, Fraternali Orcioni G, Ventura F, Palmiere C. Fatal metformin overdose: case report and postmortem biochemistry contribution. Int J Legal Med 2013; 128:483-92. [PMID: 24202696 DOI: 10.1007/s00414-013-0927-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 10/10/2013] [Indexed: 12/18/2022]
Abstract
Metformin is an oral antihyperglycemic agent used in the management of type 2 diabetes mellitus. Lactic acidosis from metformin overdose is a rare complication of metformin therapy and occurs infrequently with therapeutic use. Fatal cases, both accidental and intentional, are extremely rare in clinical practice. Metformin is eliminated by the kidneys, and impaired renal function can result in an increased plasma concentration of the drug. In this report, we describe an autopsy case involving a 70-year-old woman suffering from diabetes mellitus and impaired renal function who received metformin treatment. Metformin concentrations in the peripheral blood collected during hospitalization and femoral blood collected during autopsy were 42 and 47.3 µg/ml, respectively. Lactic acidosis (29.10 mmol/l) was objectified during hospitalization. Furthermore, postmortem biochemistry allowed ketoacidosis to be diagnosed (blood β-hydroxybutyrate, 10,500 µmol/l). Death was attributed to lactic acidosis due to metformin intoxication. Increased plasma concentrations of the drug were attributed to severely impaired renal function. The case emphasizes the usefulness of performing exhaustive toxicology and postmortem biochemistry towards the more complete understanding of the pathophysiological mechanisms that may be involved in the death process.
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The Role of Metformin in Metformin-Associated Lactic Acidosis (MALA): Case Series and Formulation of a Model of Pathogenesis. Drug Saf 2013; 36:733-46. [DOI: 10.1007/s40264-013-0038-6] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Does metformin-associated lactic acidosis really exist? Despite an old controversy, there is no doubt about it. But do we understand what is going on? Laboratory findings raised several hypotheses explaining the pathophysiology of this disease. The main cause could be an inhibition of either gluconeogenesis or mitochondrial respiratory chain complex I. From bench to bedside, one hypothesis is now confirmed in humans. Metformin poisoning involves, at least partially, a mitochondrial dysfunction.
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Affiliation(s)
- Jean-Christophe Orban
- Service de Réanimation Médico-chirurgicale, Hôpital Saint-Roch, Centre Hospitalier Universitaire de Nice, 5 rue Pierre Dévoluy, 06006 Nice, France
- IRCAN, Faculté de Médecine, Université de Nice, Avenue de Valombrose, 06107 Nice, France
| | - Eric Fontaine
- INSERM, U1055, 2280 rue de la piscine, 38041 Grenoble, France
| | - Carole Ichai
- Service de Réanimation Médico-chirurgicale, Hôpital Saint-Roch, Centre Hospitalier Universitaire de Nice, 5 rue Pierre Dévoluy, 06006 Nice, France
- IRCAN, Faculté de Médecine, Université de Nice, Avenue de Valombrose, 06107 Nice, France
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23
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Protti A, Lecchi A, Fortunato F, Artoni A, Greppi N, Vecchio S, Fagiolari G, Moggio M, Comi GP, Mistraletti G, Lanticina B, Faraldi L, Gattinoni L. Metformin overdose causes platelet mitochondrial dysfunction in humans. Crit Care 2012; 16:R180. [PMID: 23034133 PMCID: PMC3682281 DOI: 10.1186/cc11663] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 08/10/2012] [Accepted: 08/31/2012] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION We have recently demonstrated that metformin intoxication causes mitochondrial dysfunction in several porcine tissues, including platelets. The aim of the present work was to clarify whether it also causes mitochondrial dysfunction (and secondary lactate overproduction) in human platelets, in vitro and ex vivo. METHODS Human platelets were incubated for 72 hours with saline or increasing doses of metformin (in vitro experiments). Lactate production, respiratory chain complex activities (spectrophotometry), mitochondrial membrane potential (flow-cytometry after staining with JC-1) and oxygen consumption (Clark-type electrode) were then measured. Platelets were also obtained from ten patients with lactic acidosis (arterial pH 6.97 ± 0.18 and lactate 16 ± 7 mmol/L) due to accidental metformin intoxication (serum drug level 32 ± 14 mg/L) and ten healthy volunteers of similar sex and age. Respiratory chain complex activities were measured as above (ex vivo experiments). RESULTS In vitro, metformin dose-dependently increased lactate production (P < 0.001), decreased respiratory chain complex I activity (P = 0.009), mitochondrial membrane potential (P = 0.003) and oxygen consumption (P < 0.001) of human platelets. Ex vivo, platelets taken from intoxicated patients had significantly lower complex I (P = 0.045) and complex IV (P < 0.001) activity compared to controls. CONCLUSIONS Depending on dose, metformin can cause mitochondrial dysfunction and lactate overproduction in human platelets in vitro and, possibly, in vivo. TRIAL REGISTRATION NCT 00942123.
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Affiliation(s)
- Alessandro Protti
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Anna Lecchi
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Francesco Fortunato
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Andrea Artoni
- Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Noemi Greppi
- Centro Trasfusionale e di Immunoematologia, Dipartimento di Medicina Rigenerativa, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | - Sarah Vecchio
- Centro Nazionale di Informazione Tossicologica - Centro Antiveleni, Fondazione IRCCS Salvatore Maugeri, via S. Maugeri 10/10A, 27100 Pavia, Italy
| | - Gigliola Fagiolari
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Maurizio Moggio
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Giacomo Pietro Comi
- Centro Dino Ferrari - Dipartimento di Scienze Neurologiche, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
| | - Giovanni Mistraletti
- U.O. Anestesia e Rianimazione, A.O. San Paolo, Università degli Studi di Milano, via A. Di Rudiní 8, 20142 Milan, Italy
| | - Barbara Lanticina
- U.O. Rianimazione, A.O. San Carlo Borromeo, via Pio II 3, 20147 Milan, Italy
| | - Loredana Faraldi
- Servizio Anestesia e Rianimazione 1°, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Sub-Intensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, via F. Sforza 35, 20122 Milan, Italy
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Rathnapala A, Matthias T, Jayasinghe S. Severe lactic acidosis and acute renal failure following ingestion of metformin and kerosene oil: a case report. J Med Case Rep 2012; 6:18. [PMID: 22251748 PMCID: PMC3292833 DOI: 10.1186/1752-1947-6-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 01/17/2012] [Indexed: 11/24/2022] Open
Abstract
Introduction Kerosene is a freely accessible hydrocarbon used in Sri Lankan (and other Asian) households for cooking and for lighting lamps. Kerosene poisoning is rarely reported among adults and its toxicological effects are not well known. Metformin is a commonly used oral hypoglycemic drug and its overdose leads primarily to lactic acidosis. Combined poisoning of metformin and kerosene and their interactions have not been reported. Case presentation An 18-year-old, previously healthy, unmarried Sinhalese woman was referred following ingestion of 17.5 g of metformin and approximately 200 mL of kerosene oil in a suicide attempt. She had vomiting, burning epigastric pain, and a hypoglycemic seizure (capillary blood glucose of 42 mg/dL). Subsequently, she developed severe lactic acidosis followed by acute renal insufficiency, was treated with sodium bicarbonate, and underwent intermittent hemodialysis with bicarbonate. She recovered completely. Conclusions This report proposes possible interactions that occur between metformin and kerosene that augment toxicity when the two are ingested together. It also stresses the importance of early treatment with intermittent hemodialysis in severe lactic acidosis with maintenance of blood glucose.
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Furukawa S, Kumagi T, Miyake T, Ueda T, Niiya T, Nishino K, Murakami S, Murakami M, Matsuura B, Onji M. Suicide attempt by an overdose of sitagliptin, an oral hypoglycemic agent: a case report and a review of the literature. Endocr J 2012; 59:329-33. [PMID: 22277726 DOI: 10.1507/endocrj.ej11-0390] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Dipeptidyl peptidase-4 (DPP-4) inhibitors are a newer class of oral hypoglycemic agents for the management of diabetes that elevate the plasma concentration of active glucagon-like peptide-1 via inhibition of DPP-4. They effectively lower not only glycosylated hemoglobin levels, but also fasting and postprandial plasma glucose levels. Patients with diabetes occasionally consume an overdose of oral hypoglycemic agents in suicide attempts: the prevalence of depression is high in patients with diabetes, and depression is a strong risk factor for suicide. We encountered an 86-year-old woman with type 2 diabetes and depression, who was transferred to the emergency room 4h after ingestion of 1,700 mg of the DPP-4 inhibitor sitagliptin (1,700 mg is 17 times greater than the approved maximum dose). Upon arrival, she was fully conscious, plasma glucose was 124 mg/dL, and serum immunoreactive insulin level was 5.81 µU/mL. Thereafter, the plasma concentration of sitagliptin rose to 3,793 nM, which is 4.5 times higher than the value found under regular treatment with the maximum dose. The patient did not suffer from hypoglycemia, suggesting that a single oral overdose of sitagliptin is unlikely to cause hypoglycemia. A literature review of oral anti-diabetic agents revealed that overdose of biguanides is occasionally fatal when immediate intensive care is not provided. In summary, sitagliptin is a good treatment option for diabetic elderly patients or patients with psychiatric disorders who are suicidal and do not require insulin.
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Affiliation(s)
- Shinya Furukawa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan.
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Yeung CW, Chung HY, Fong BMW, Tsai NW, Chan WM, Siu TS, Tam S, Tsui SH. Metformin-associated lactic acidosis in Chinese patients with type II diabetes. Pharmacology 2011; 88:260-5. [PMID: 21996640 DOI: 10.1159/000331867] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 08/08/2011] [Indexed: 11/19/2022]
Abstract
Metformin is a widely used antidiabetic agent that is generally considered safe. However, metformin-associated lactic acidosis (MALA), though not common, occurs from time to time and results in significantly high mortality. A series of 23 MALA cases in a local major hospital in Hong Kong is reported in this article to demonstrate the epidemiological data, risk factors, clinical features as well as the clinical outcomes for better understanding of this disease entity. It is the first MALA case series in which plasma metformin levels were assessed. However, the results show that plasma metformin levels in MALA bear no diagnostic and prognostic values. Risk factors of mortality were identified as shock and high plasma lactate levels. The majority of patients were found to have significantly raised creatinine versus a normal baseline value before the acute illness. Concomitant illnesses taking place alongside MALA were common. With a high utility rate of renal replacement therapy (82.6%) in the study group, the mortality rate was 30.4%.
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Affiliation(s)
- Chun Wing Yeung
- Division of Clinical Biochemistry, Queen Mary Hospital, Hong Kong, SAR, China. ycw186 @ ha.org.hk
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Li Cavoli G, Tortorici C, Bono L, Ferrantelli A, Rotolo U. Acute kidney injury in a patient with psychological eating disorder. Clin Exp Nephrol 2011; 15:793-794. [PMID: 21706140 DOI: 10.1007/s10157-011-0480-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Accepted: 06/07/2011] [Indexed: 11/25/2022]
Affiliation(s)
- Gioacchino Li Cavoli
- Division of Nephrology and Dialysis, Civic and Di Cristina Hospital, via Francesco Cilea 43, Palermo, 90144, Italy.
| | - Calogera Tortorici
- Division of Nephrology and Dialysis, Civic and Di Cristina Hospital, via Francesco Cilea 43, Palermo, 90144, Italy
| | - Luisa Bono
- Division of Nephrology and Dialysis, Civic and Di Cristina Hospital, via Francesco Cilea 43, Palermo, 90144, Italy
| | - Angelo Ferrantelli
- Division of Nephrology and Dialysis, Civic and Di Cristina Hospital, via Francesco Cilea 43, Palermo, 90144, Italy
| | - Ugo Rotolo
- Division of Nephrology and Dialysis, Civic and Di Cristina Hospital, via Francesco Cilea 43, Palermo, 90144, Italy
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Acute kidney injury associated with metformin. Am J Emerg Med 2011; 29:568-9. [DOI: 10.1016/j.ajem.2011.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Accepted: 02/20/2011] [Indexed: 11/23/2022] Open
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Shuster J. Metformin-Associated Lactic Acidosis; Escitalopram-Related Rhabdomyolysis; Adalimumab-Induced Disseminated Superficial Porokeratosis; Nephrotic Syndrome Associated with Adalimumab; Methotrexate-Induced Periorbital Radiation Recall; Micturition Difficulty Associated with Aripiprazole; Aripiprazole-Related Acute Transient Myopia and Diplopia; Intestinal Necrosis Associated with Calcium Polystyrene Sulfonate. Hosp Pharm 2011. [DOI: 10.1310/hpj4605-314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs to the US Food and Drug Administration's (FDA's) MedWatch program (800-FDA-1088). If you have reported an interesting, preventable ADR to MedWatch, please consider sharing the account with our readers.
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Affiliation(s)
- Joel Shuster
- Temple University School of Pharmacy, Philadelphia, Pennsylvania; Clinical Consultant, Episcopal Hospital, Pennsylvania; Institute for Safe Medication Practices, Horsham, Pennsylvania
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Soyoral YU, Begenik H, Emre H, Aytemiz E, Ozturk M, Erkoc R. Dialysis therapy for lactic acidosis caused by metformin intoxication: presentation of two cases. Hum Exp Toxicol 2011; 30:1995-7. [DOI: 10.1177/0960327111403177] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Metformin is an oral antidiabetic, which is frequently used in the treatment of type II diabetes mellitus. Serious side effects may be seen during the administration of high doses of metformin. Two cases of lactic acidosis due to ingestion of high dose metformin for suicidal purposes have been presented here; in both cases, clinical improvement was seen with bicarbonate hemodialysis.
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Affiliation(s)
- Yasemin Usul Soyoral
- Department of Nephrology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Huseyin Begenik
- Department of Nephrology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Habib Emre
- Department of Nephrology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Enver Aytemiz
- Department of Internal Medicine, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Mustafa Ozturk
- Department of Endocrinology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Reha Erkoc
- Department of Nephrology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
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31
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Metformin-associated lactic acidosis: is it really just an association? Am J Emerg Med 2011; 29:349-50. [PMID: 21159476 DOI: 10.1016/j.ajem.2010.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 10/23/2010] [Indexed: 11/22/2022] Open
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Friesecke S, Abel P, Roser M, Felix SB, Runge S. Outcome of severe lactic acidosis associated with metformin accumulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R226. [PMID: 21171991 PMCID: PMC3220003 DOI: 10.1186/cc9376] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 07/14/2010] [Accepted: 12/20/2010] [Indexed: 01/31/2023]
Abstract
Introduction Metformin associated lactic acidosis (MALA) may complicate metformin therapy, particularly if metformin accumulates due to renal dysfunction. Profound lactic acidosis (LA) generally predicts poor outcome. We aimed to determine if MALA differs in outcome from LA of other origin (LAOO). Methods We conducted a retrospective analysis of all patients admitted with LA to our medical ICU of a tertiary referral center during a 5-year period. MALA patients and LAOO patients were compared with respect to parameters of acid-base balance, serum creatinine, hospital outcome, Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) score, using Pearson's Chi-square or the Mann-Whitney U-test. Results Of 197 patients admitted with LA, 10 had been diagnosed with MALA. With MALA, median arterial blood pH was significantly lower (6.78 [range 6.5 to 6.94]) and serum lactate significantly higher (18.7 ± 5.3 mmol/L) than with LAOO (pH 7.20 [range 6.46 to 7.35], mean serum lactate 11.2 ± 6.1 mmol/L). Overall mortality, however, was comparable (MALA 50%, LAOO 74%). Furthermore, survival of patients with arterial blood pH < 7.00 (N = 41) was significantly better (50% vs. 0%) if MALA (N = 10) was the underlying condition compared to LAOO (N = 31). Conclusions Compared to similarly severe lactic acidosis of other origin, the prognosis of MALA is significantly better. MALA should be considered in metformin-treated patients presenting with lactic acidosis.
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Affiliation(s)
- Sigrun Friesecke
- Department of Cardiology, Pneumology and Intensive Care Medicine, Ernst Moritz Arndt University, 17475 Greifswald, Germany.
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