1
|
Kuan IHS, Savage RL, Duffull SB, Walker RJ, Wright DFB. The Association between Metformin Therapy and Lactic Acidosis. Drug Saf 2020; 42:1449-1469. [PMID: 31372935 DOI: 10.1007/s40264-019-00854-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is increasing evidence to suggest that therapeutic doses of metformin are unlikely to cause lactic acidosis. The aims of this research were (1) to formally evaluate the association between metformin therapy and lactic acidosis in published case reports using two causality scoring systems, (2) to determine the frequency of pre-existing independent risk factors in published metformin-associated lactic acidosis cases, (3) to investigate the association between risk factors and mortality in metformin-associated lactic acidosis cases, and (4) to explore the relationship between prescribed metformin doses, elevated metformin plasma concentrations and the development of lactic acidosis in cases with chronic renal impairment. METHODS A systematic review was conducted to identify metformin-associated lactic acidosis cases. Causality was assessed using the World Health Organisation-Uppsala Monitoring Centre system and the Naranjo adverse drug reaction probability scale. Compliance to dosing guidelines was investigated for cases with chronic renal impairment as well as the association between steady-state plasma metformin concentrations prior to admission. RESULTS We identified 559 metformin-associated lactic acidosis cases. Almost all cases reviewed (97%) presented with independent risk factors for lactic acidosis. The prescribed metformin dose exceeded published guidelines in 60% of cases in patients with impaired kidney function. Metformin steady-state plasma concentrations prior to admission were predicted to be below the proposed upper limit of the therapeutic range of 5 mg/L. CONCLUSIONS Almost all cases of metformin-associated lactic acidosis reviewed presented with independent risk factors for lactic acidosis, supporting the suggestion that metformin plays a contributory role. The prescribed metformin dose, on average, exceeded the dosing recommendations by 1000 mg/day in patients with varying degrees of renal impairment but the predicted pre-admission plasma concentrations did not exceed the therapeutic range.
Collapse
Affiliation(s)
- Isabelle H S Kuan
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Ruth L Savage
- New Zealand Pharmacovigilance Centre, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Stephen B Duffull
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Robert J Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Daniel F B Wright
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand.
| |
Collapse
|
2
|
Blumenberg A, Benabbas R, Sinert R, Jeng A, Wiener SW. Do Patients Die with or from Metformin-Associated Lactic Acidosis (MALA)? Systematic Review and Meta-analysis of pH and Lactate as Predictors of Mortality in MALA. J Med Toxicol 2020; 16:222-229. [PMID: 31907741 PMCID: PMC7099117 DOI: 10.1007/s13181-019-00755-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/04/2019] [Accepted: 12/15/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Metformin-associated lactic acidosis (MALA) may occur after acute metformin overdose, or from therapeutic use in patients with renal compromise. The mortality is high, historically 50% and more recently 25%. In many disease states, lactate concentration is strongly associated with mortality. The aim of this systematic review and meta-analysis is to investigate the utility of pH and lactate concentration in predicting mortality in patients with MALA. METHODS We searched PubMed, EMBASE, and Web of Science from their inception to April 2019 for case reports, case series, prospective, and retrospective studies investigating mortality in patients with MALA. Cases and studies were reviewed by all authors and included if they reported data on pH, lactate, and outcome. Where necessary, authors of studies were contacted for patient-level data. Receiver operating characteristic (ROC) curves were generated for pH and lactate for predicting mortality in patients with MALA. RESULTS Forty-four studies were included encompassing 170 cases of MALA with median age of 68.5 years old. Median pH and lactate were 7.02 mmol/L and 14.45 mmol/L, respectively. Overall mortality was 36.2% (95% CI 29.6-43.94). Neither lactate nor pH was a good predictor of mortality among patients with MALA. The area under the ROC curve for lactate and pH were 0.59 (0.51-0.68) and 0.43 (0.34-0.52), respectively. CONCLUSION Our review found higher mortality from MALA than seen in recent studies. This may be due to variation in standard medical practice both geographically and across the study interval, sample size, misidentification of MALA for another disease process and vice versa, confounding by selection and reporting biases, and treatment intensity (e.g., hemodialysis) influenced by degree of pH and lactate derangement. The ROC curves showed poor predictive power of either lactate or pH for mortality in MALA. With the exception of patients with acute metformin overdose, patients with MALA usually have coexisting precipitating illnesses such as sepsis or renal failure, though lactate from MALA is generally higher than would be considered survivable for those disease states on their own. It is possible that mortality is more related to that coexisting illness than MALA itself, and many patients die with MALA rather than from MALA. Additional work looking solely at MALA in healthy patients with acute metformin overdose may show a closer relationship between lactate, pH, and mortality.
Collapse
Affiliation(s)
- Adam Blumenberg
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA.
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA.
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA.
| | - Roshanak Benabbas
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Richard Sinert
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Amy Jeng
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Sage W Wiener
- Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY, USA
- Department of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| |
Collapse
|
3
|
Al-Hwiesh AK, Abdul-Rahman IS, Noor AS, Nasr-El-Deen MA, Abdelrahman A, El-Salamoni TS, Al-Muhanna FA, Al-Otaibi K, Al-Audah N. The Phantom of Metformin-Induced Lactic Acidosis in End-Stage Renal Disease Patients: Time to Reconsider with Peritoneal Dialysis Treatment. Perit Dial Int 2020; 37:56-62. [DOI: 10.3747/pdi.2015.00309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 05/17/2016] [Indexed: 01/22/2023] Open
Abstract
ObjectiveMetformin continues to be the safest and most widely used antidiabetic drug. In spite of its well-known benefits; metformin use in end-stage renal disease (ESRD) patients is still restricted. Little has been reported about the effect of peritoneal dialysis (PD) on metformin clearance and the phantom of lactic acidosis deprives ESRD patients from metformin therapeutic advantages. Peritoneal dialysis is probably a safeguard against lactic acidosis, and it is likely that using this drug would be feasible in this group of patients.Material and methodsThe study was conducted on 83 PD patients with type 2 diabetes mellitus. All patients were on automated PD (APD). Metformin was administered in a dose of 500 - 1,000 mg daily. Patients were monitored for glycemic control. Plasma lactic acid and plasma metformin levels were monitored on a scheduled basis. Peritoneal fluid metformin levels were measured. In addition, the relation between plasma metformin and plasma lactate was studied.ResultsMean fasting blood sugar (FBS) was 10.9 ± 0.5 and 7.8 ± 0.7, and mean hemoglobin A1-C (HgA1C) was 8.2 ± 0.8 and 6.4 ± 1.1 at the beginning and end of the study, respectively (p < 0.001). The mean body mass index (BMI) was 29.1 ± 4.1 and 27.3 ± 4.5 at the beginning and at the end of the study, respectively (p < 0.001). The overall mean plasma lactate level across all blood samples was 1.44 ± 0.6. Plasma levels between 2 and 3 mmol/L were found in 11.8% and levels of 3 - 3.6 mmol/L in 2.4% plasma samples. Hyperlactemia (level > 2 and < 5 mmol/L) was not associated with overt acidemia. None of our patients had lactic acidosis (levels > 5 mmol/L). Age ≥ 60 was a predictor for hyperlactemia. No relationship was found between plasma metformin and lactate levels.ConclusionMetformin may be used with caution in a particular group of ESRD patients who are on APD. Metformin allows better diabetic control with significant reduction of BMI. Information on the relationship between metformin and plasma lactate levels is lacking. Peritoneal dialysis appears to be a safeguard against the development of lactic acidosis in this group of patients.
Collapse
Affiliation(s)
| | | | - Abdul-Salam Noor
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
| | | | - Abdalla Abdelrahman
- Nephrology Division, King Fahd Hospital of the University, University of Dammam, Saudi Arabia; and Department of Electrical Engineering, Queens University, Kingston, Ontario, Canada
| | | | - Fahd A. Al-Muhanna
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
| | - Khalid Al-Otaibi
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
| | - Nehad Al-Audah
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
| |
Collapse
|
4
|
Abdel Shaheed C, Carland JE, Graham GG, Stocker SL, Smith G, Hicks M, Williams KM, Furlong T, Macdonald P, Greenfield JR, Smith FC, Chowdhury G, Day RO. Is the use of metformin in patients undergoing dialysis hazardous for life? A systematic review of the safety of metformin in patients undergoing dialysis. Br J Clin Pharmacol 2019; 85:2772-2783. [PMID: 31471973 DOI: 10.1111/bcp.14107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/04/2019] [Accepted: 08/18/2019] [Indexed: 12/22/2022] Open
Abstract
AIMS Metformin may have clinical benefits in dialysis patients; however, its safety in this population is unknown. This systematic review evaluated the safety of metformin in dialysis patients. METHODS MEDLINE, Embase, CENTRAL, PsycINFO and the Cochrane Library were searched for randomised controlled trials and observational studies evaluating metformin use in dialysis patients. Three authors reviewed the studies and extracted data. The primary outcomes were mortality, occurrence of lactic acidosis and myocardial infarction (MI) in patients taking metformin during dialysis treatment for ≥12 months (long term). Risk of bias was assessed using Risk Of Bias In Nonrandomised Studies of Interventions (ROBINS-1). Overall quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Fifteen observational studies were eligible; 7 were prospective observational studies and 8 were case reports/case series. No randomised controlled trials were identified. The 7 prospective observational studies (n = 194) reported on cautious metformin use in patients undergoing maintenance dialysis. Only 3 provided long-term follow-up data. In 2 long-term studies of metformin therapy (≤1000 mg/d) in patients undergoing peritoneal dialysis (PD), 1 reported 6 deaths (6/83; 7%) due to major cardiovascular events (3 MI) and the other reported no deaths (0/35). One long-term study of metformin therapy (250 mg to 500 mg thrice weekly) in patients undergoing haemodialysis reported 4 deaths (4/61; 7%) due to major cardiovascular events (2 MI). These findings provide very low-quality evidence as they come from small observational studies. CONCLUSION The evidence regarding the safety of metformin in people undergoing dialysis is inconclusive. Appropriately designed randomised controlled trials are needed to resolve this uncertainty.
Collapse
Affiliation(s)
- Christina Abdel Shaheed
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Greg Smith
- Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Mark Hicks
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Kenneth M Williams
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Timothy Furlong
- Department of Nephrology, St Vincent's Hospital, Sydney, Australia
| | - Peter Macdonald
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,The Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Jerry R Greenfield
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia.,Diabetes and Metabolism Division, Garvan Institute of Metabolic Research, Sydney, Australia.,Department of Diabetes and Endocrinology, St Vincent's Hospital, Sydney, Australia
| | - Felicity C Smith
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Gina Chowdhury
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,Department of Pharmacology, School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| |
Collapse
|
5
|
Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med 2015; 43:1716-30. [PMID: 25860205 DOI: 10.1097/ccm.0000000000001002] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Metformin toxicity, a challenging clinical entity, is associated with a mortality of 30%. The role of extracorporeal treatments such as hemodialysis is poorly defined at present. Here, the Extracorporeal Treatments In Poisoning workgroup, comprising international experts representing diverse professions, presents its systematic review and clinical recommendations for extracorporeal treatment in metformin poisoning. METHODS A systematic literature search was performed, data extracted, findings summarized, and structured voting statements developed. A two-round modified Delphi method was used to achieve consensus on voting statements and RAND/UCLA Appropriateness Method to quantify disagreement. Anonymized votes and opinions were compiled and discussed. A second vote determined the final recommendations. RESULTS One hundred seventy-five articles were identified, including 63 deaths: one observational study, 160 case reports or series, 11 studies of descriptive cohorts, and three pharmacokinetic studies in end-stage renal disease, yielding a very low quality of evidence for all recommendations. The workgroup concluded that metformin is moderately dialyzable (level of evidence C) and made the following recommendations: extracorporeal treatment is recommended in severe metformin poisoning (1D). Indications for extracorporeal treatment include lactate concentration greater than 20 mmol/L (1D), pH less than or equal to 7.0 (1D), shock (1D), failure of standard supportive measures (1D), and decreased level of consciousness (2D). Extracorporeal treatment should be continued until the lactate concentration is less than 3 mmol/L (1D) and pH greater than 7.35 (1D), at which time close monitoring is warranted to determine the need for additional courses of extracorporeal treatment. Intermittent hemodialysis is preferred initially (1D), but continuous renal replacement therapies may be considered if hemodialysis is unavailable (2D). Repeat extracorporeal treatment sessions may use hemodialysis (1D) or continuous renal replacement therapy (1D). CONCLUSION Metformin poisoning with lactic acidosis appears to be amenable to extracorporeal treatments. Despite clinical evidence comprised mostly of case reports and suboptimal toxicokinetic data, the workgroup recommended extracorporeal removal in the case of severe metformin poisoning.
Collapse
|
6
|
Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min). Nephrol Dial Transplant 2015; 30 Suppl 2:ii1-142. [PMID: 25940656 DOI: 10.1093/ndt/gfv100] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
7
|
Helvaci MR, Sevinc A, Camci C, Yalcin A. Treatment of White Coat Hypertension With Metformin. Int Heart J 2008; 49:671-9. [DOI: 10.1536/ihj.49.671] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
8
|
Abstract
Lactic acidosis is frequently encountered in the intensive care unit. It occurs when there is an imbalance between production and clearance of lactate. Although lactic acidosis is often associated with a high anion gap and is generally defined as a lactate level >5 mmol/L and a serum pH <7.35, the presence of hypoalbuminemia may mask the anion gap and concomitant alkalosis may raise the pH. The causes of lactic acidosis are traditionally divided into impaired tissue oxygenation (Type A) and disorders in which tissue oxygenation is maintained (Type B). Lactate level is often used as a prognostic indicator and may be predictive of a favorable outcome if it normalizes within 48 hours. The routine measurement of serum lactate, however, should not determine therapeutic interventions. Unfortunately, treatment options remain limited and should be aimed at discontinuation of any offending drugs, treatment of the underlying pathology, and maintenance of organ perfusion. The mainstay of therapy of lactic acidosis remains prevention.
Collapse
Affiliation(s)
- Pamela J Fall
- Section of Nephrology, Hypertension and Transplantation, Department of Medicine, Medical College of Georgia, Augusta 30912, USA
| | | |
Collapse
|
9
|
Stades AME, Heikens JT, Erkelens DW, Holleman F, Hoekstra JBL. Metformin and lactic acidosis: cause or coincidence? A review of case reports. J Intern Med 2004; 255:179-87. [PMID: 14746555 DOI: 10.1046/j.1365-2796.2003.01271.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Metformin has been associated with the serious side-effect lactic acidosis. However, it remains unclear whether the use of metformin was a cause or a coincidence in lactic acidosis. DESIGN A literature search of the Index Medicus (1959-66) and of the databases Embase, Medline, Medline Express (1966-99) was performed using the keywords metformin, biguanides and lactic acidosis. All articles of cases with metformin-induced lactic acidosis (MILA) were cross-referenced. SUBJECTS Cases were included for analysis if they met the following criteria: serum pH < or =7.35, lactate concentration > or =5 mmol L(-1). INTERVENTION A forum of six experts in intensive care medicine independently categorized the cases in MILA unlikely (score 0), possible MILA (score 1) or probable MILA (score 2). MAIN OUTCOME MEASURES Statistical analysis included the paired interobserver agreement (kappa) and multivariate regression analysis. RESULTS Of 80 reported cases, 33 were excluded because of insufficient quality. The forum scores of the remaining 47 cases were distributed normally with a mean score of 7 (range 2-10). The kappa-value was 0.041 (SD = 0.24, range -0.514, 0.427). Neither lactate concentration nor mortality correlated with serum metformin concentrations. CONCLUSIONS Given the low interobserver agreement and the lack of any relationship between metformin levels and outcome parameters, the concept that there is a simple, causal relationship between metformin use and lactic acidosis in diabetic patients has to be reconsidered.
Collapse
Affiliation(s)
- A M E Stades
- Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands.
| | | | | | | | | |
Collapse
|
10
|
Lalau JD, Race JM. Lactic acidosis in metformin therapy: searching for a link with metformin in reports of 'metformin-associated lactic acidosis'. Diabetes Obes Metab 2001; 3:195-201. [PMID: 11412284 DOI: 10.1046/j.1463-1326.2001.00128.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The link between metformin and lactic acidosis in metformin therapy may be causal, associated or coincidental. Our objective was to investigate this link by studying and analysing published reports of so-called 'metformin-associated lactic acidosis'. RESEARCH DESIGN AND METHODS systematically searched in the BIOSIS, DERWENT, EMBASE, MEDLINE, and PASCAL databases of the English language and non-English language literature for all reports of so-called 'metformin-associated lactic acidosis' published from May 1995 through January 2000. We did not include reports related to metformin overdose or contrast media-induced renal failure. Metformin accumulation and concurrent pathologies were critically reviewed as precipitating factors for metformin-associated lactic acidosis. Metformin accumulation was assessed in terms of the recorded measurement of metformin concentration in plasma or, if not available, by the presence of primary renal failure, i.e. renal failure that was not secondary to a shock syndrome. RESULTS We found 21 reports describing a total of 26 patients. Criteria of lactic acidosis (lactate > 5 mmol/l, pH <or= 7.35) were not met in four patients. In the remaining 22 patients, plasma metformin concentration was determined in only four, of whom one had a normal value. In the 18 patients with lactic acidosis where plasma metformin concentration data was not available, the presence of primary renal failure was absent or unlikely in six patients, uncertain in two, and likely or proven in 14. With regard to these 14 patients, the precipitating factor was metformin in 12 patients (in the context of renal failure either chronic or acute) and intercurrent pathologies in two others. Overall, lactic acidosis was either absent (n = 4), precipitated by concurrent pathology (n = 8), precipitated by metformin without apparent associated pathology (n = 12) or of uncertain origin (n = 2). Death occurred 10 times but only once in the 12 patients with metformin-induced lactic acidosis and this was not related to metformin. CONCLUSIONS While the term 'metformin-associated lactic acidosis' is commonly used to depict all situations of lactic acidosis in metformin therapy, true metformin-associated lactic acidosis, i.e. one which refers to metformin and concurrent pathologies as co-precipitating factors, was never observed in the studied reports. As there was no mortality due to metformin alone, it is important that physicians are familiar with the range of other risk factors that contribute to lactic acidosis in patients treated with metformin.
Collapse
Affiliation(s)
- J D Lalau
- Service d'Endocrinologie-Nutrition, Hôpital Universitaire, Amiens, France.
| | | |
Collapse
|
11
|
Abstract
In 1995, the oral antihyperglycemic agent, metformin, was introduced in the United States for treating diabetes mellitus. Rare cases of metformin-associated lactic acidosis caused by the accumulation of the drug in patients with renal dysfunction have been described, although a detailed time course of the resulting metabolic derangements has not been reported. A case of metformin-associated lactic acidosis is presented along with key serial laboratory abnormalities observed during the treatment phase. The patient made a complete recovery following therapy with hemodialysis and supportive care.
Collapse
Affiliation(s)
- J A Kruse
- Detroit Receiving Hospital and Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| |
Collapse
|
12
|
Abbasi AA, Kasmikha R, Sotingeanu DG. Metformin-induced lacticacidemia in patients with type 2 diabetes mellitus. Endocr Pract 2000; 6:442-6. [PMID: 11155215 DOI: 10.4158/ep.6.6.442] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether metformin therapy can predispose patients with type 2 diabetes and normal renal function to lactic acidosis when certain conditions are present. METHODS We undertook this prospective cohort study in 110 consecutive patients (age range, 27 to 85 years) with normal serum creatinine levels (<1.5 mg/dL in men; <1.4 mg/dL in women), receiving metformin as monotherapy or in combination with sulfonylurea or insulin, who were undergoing assessment on a regular basis for diabetes care. Clinical evaluations were performed at 4- to 12-week intervals for up to 2 years. Serum electrolytes and creatinine as well as plasma lactic acid determinations were done in all patients, regardless of symptoms. The anion gap was calculated. RESULTS Plasma lactic acid concentrations were normal in 47 patients (mean, 9.4 +/- 18.0 mg/dL or 1.053 +/- 0.194 mmol/L) and high in 63 patients (19.63 +/- 5.11 mg/dL or 2.208 +/- 0.569 mmol/L; P<0.001). The anion gap was increased in the high lactic acid group in comparison with the normal group (P<0.001). Comorbid conditions (for example, cardiovascular or respiratory disease) that may predispose to hypoxemia or compromise tissue perfusion were significantly more prevalent in patients in the high lactic acid group than in those with normal lactic acid values. CONCLUSION Lacticacidemia may occur in metformin-treated patients with type 2 diabetes mellitus who have normal renal function. An increased anion gap and certain clinical symptoms may serve as clues for the presence of lacticacidemia. Progression from lacticacidemia to clinical lactic acidosis, under certain hemodynamic or respiratory adverse conditions, remains conjectural and needs further evaluation.
Collapse
Affiliation(s)
- A A Abbasi
- Diabetes and Endocrinology Center, Bloomfield Hills, MI, USA
| | | | | |
Collapse
|
13
|
Abstract
AIMS Lactic acidosis is a well recognized complication of biguanide therapy which is potentially serious. Although the prevalence of metformin-associated lactic acidosis (MALA) is much lower than that associated with phenformin, it is still being reported sporadically which raises concerns for the practising clinicians. We review the currently available world-wide data of the prevalence of MALA, the risk factors for its development and the current practical guidelines on the use of metformin to minimize the risk of this potential hazard. METHODS An extensive literature search was conducted from both Medline and Ovid (1965-98) using the following keywords: 'Type 2 diabetes mellitus', 'oral hypoglycaemic drugs', 'biguanides', 'metformin-associated lactic acidosis' and 'renal impairment'. RESULTS MALA was found to be a very rare clinical entity, being 20 times less common than phenformin-associated lactic acidosis. Amongst all the risk factors, renal impairment appears to be the major precipitating factor for the development of MALA in metformin-treated patients. We also found cases of MALA where no precipitating factors were identified and the underlying mechanism in these cases remains unclear. Practical recommendations of metformin use to minimize the risk of MALA have been listed based on previous reports. CONCLUSIONS The low prevalence of MALA is comparable to the prevalence of sulphonylurea-induced hypoglycaemia. Metformin has many beneficial metabolic effects in the management of Type 2 diabetes mellitus. Provided that the recommended guidelines for metformin use are strictly adhered to, its widespread use would be safe and the incidence of MALA will be further reduced.
Collapse
Affiliation(s)
- N N Chan
- Diabetes Unit, Medicine Directorate, Imperial College School of Medicine, Chelsea & Westminster Hospital, London. NN KA
| | | | | |
Collapse
|