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Qureshi R, Nasir K, Dhrolia M, Ahmad A. A Comparative Study of Acidosis in Diabetic Advanced Chronic Kidney Disease Patients on and off Metformin. Cureus 2022; 14:e21291. [PMID: 35186553 PMCID: PMC8846262 DOI: 10.7759/cureus.21291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 11/29/2022] Open
Abstract
Aim The aim of the study is to assess the risk of acidosis in diabetic advanced chronic kidney disease (CKD) patients on and off metformin. Methods This retrospective descriptive study was conducted in the nephrology department in The Kidney Centre Post Graduate Training Institute (TKC PGTI) Karachi from February to April 2020. We reviewed the records of all patients over 18 years old who visited the nephrology outpatient department in three months in 2020 (from February 2020 to April 2020), who had CKD (stage 2-5), are not on dialysis, and had type 2 diabetes. These were divided into two groups: those on metformin for more than one year and those not on metformin. We looked at hospitalizations due to acidosis in the previous one-year period. Results A total of 524 CKD patients had diabetes; out of those, 268 patients were on metformin, and 256 were not on metformin. The male vs. female distribution was 52.1% vs. 47.9%. A total of 114 (21.8%) patients required admission in the previous one-year period, and only 12 hospitalized patients had acidosis, seven (58.3%) were on metformin, and five (41.7%) were not on metformin, which was statistically insignificant. Conclusion Biguanides, especially metformin, is a known oral hypoglycemic drug used for decades to treat type 2 diabetes mellitus (DM). Metformin use is related to a rare but serious adverse event, metformin-associated lactic acidosis (MALA), especially in renal failure patients. In our study, metformin use in CKD diabetic patients did not result in more admissions due to acidosis than non-metformin users.
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Puri P, Kotwal N. An Approach to the Management of Diabetes Mellitus in Cirrhosis: A Primer for the Hepatologist. J Clin Exp Hepatol 2022; 12:560-574. [PMID: 35535116 PMCID: PMC9077234 DOI: 10.1016/j.jceh.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/07/2021] [Indexed: 12/12/2022] Open
Abstract
The management of diabetes in cirrhosis and liver transplantation can be challenging. There is difficulty in diagnosis and monitoring of diabetes as fasting blood sugar values are low and glycosylated hemoglobin may not be a reliable marker. The challenges in the management of diabetes in cirrhosis include the likelihood of cognitive impairment, risk of hypoglycemia, altered drug metabolism, frequent renal dysfunction, risk of lactic acidosis, and associated malnutrition and sarcopenia. Moreover, calorie restriction and an attempt to lose weight in obese diabetics may be associated with a worsening of sarcopenia. Many commonly used antidiabetic drugs may be unsafe or be associated with a high risk of hypoglycemia in cirrhotics. Post-transplant diabetes is common and may be contributed by immunosuppressive medication. There is inadequate clinical data on the use of antidiabetic drugs in cirrhosis, and the management of diabetes in cirrhosis is hampered by the lack of guidelines focusing on this issue. The current review aims at addressing the practical management of diabetes by a hepatologist.
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Key Words
- ADA, American Diabetes Association
- AGI, Alfa Glucosidase inhibitors
- BMI, Body mass index
- CLD, Chronic liver disease
- CYP-450, Cytochrome P-450
- Dipeptidyl-peptidase 4, DPP-4
- GLP-1, Glucagon-like peptide-1
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C virus
- HbA1c, Hemoglobin A1c
- IGF, Insulin-like growth factor
- MALA, Metformin-associated lactic acidosis
- NASH, Nonalcoholic steatohepatitis
- NPL, Neutral protamine lispro
- OGTT, Oral glucose tolerance test
- SMBG, Self-monitoring of blood glucose
- Sodium-glucose cotransporter 2, SGLT2
- VEGF, Vascular endothelial growth factor
- antidiabetic agents
- antihyperglycemic drugs
- chronic liver disease
- cirrhosis
- diabetes mellitus
- eGFR, estimated glomerular filtration rates
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Affiliation(s)
- Pankaj Puri
- Fortis Escorts Liver and Digestive Diseases Institute, New Delhi, 110025, India,Address for correspondence: Dr Pankaj Puri, DNB, DM (Gastroenterology), FRCP (Edinburgh), FRCP (London) Director, Gastroenterology and Hepatology Fortis Escorts Hospital Okhla Road, New Delhi, 110025, India.
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Escott GM, da Silveira LG, Cancelier VDA, Dall'Agnol A, Silveiro SP. Monitoring and management of hyperglycemia in patients with advanced diabetic kidney disease. J Diabetes Complications 2021; 35:107774. [PMID: 33168397 DOI: 10.1016/j.jdiacomp.2020.107774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/10/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022]
Abstract
Diabetes mellitus is the leading cause of end-stage renal disease, and uncontrolled hyperglycemia is directly related to the increased mortality in this setting. As kidney function decreases, it becomes more challenging to control blood glucose since the risk of hypoglycemia increases. Decreased appetite, changes in glycaemia homeostasis, along with reduced renal excretion of anti-hyperglycemic drugs tend to facilitate the occurrence of hypoglycemia, despite the paradoxical occurrence of insulin resistance in advanced kidney disease. Thus, in patients using insulin and/or oral anti-hyperglycemic agents, dynamic adjustments with drug dose reduction or drug switching are often necessary. Furthermore, in addition to consider these pharmacokinetics alterations, it is of utmost importance to choose drugs with proven cardio-renal benefits in this setting, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. In this review, we summarize the indications and contraindications, titration of doses and side effects of the available anti-hyperglycemic agents in the presence of advanced diabetic kidney disease (DKD) and dialysis, highlighting the risks and benefits of the different agents. Additionally, basic renal function assessment and monitoring of glycemic control in DKD will be evaluated in order to guide the use of drugs and define the glycemic targets to be achieved.
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Affiliation(s)
- Gustavo Monteiro Escott
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil
| | | | | | - Angélica Dall'Agnol
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil
| | - Sandra Pinho Silveiro
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil; Endocrine Unit, Hospital de Clínicas de Porto Alegre, RS, Brazil.
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Schädle P, Tschritter O, Kellerer M. Metformin Associated Lactic Acidosis in Clinical Practice - A Case Series. Exp Clin Endocrinol Diabetes 2020; 129:842-847. [PMID: 32403137 DOI: 10.1055/a-1149-9030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AIMS The aim of this case report is to specify the frequency and mortality of Metformin-Associated Lactic Acidosis (MALA) in emergency medicine, as the diagnosis seems to occur more often than estimated. METHODS To identify the subjects, we developed screening criteria for MALA. We measured the serum metformin concentration to confirm the diagnosis in all patients fulfilling these criteria. Retrospectively the patients were grouped according to individual risk (according to a defined risk score) and the application of renal replacement therapy. RESULTS From 2013 until 2018 we were able to identify 11 MALA patients revealing a frequency of 1:4,000 emergency patients. Six patients survived and five died in the follow-up. All three patients in the high-risk group died although all of them received renal replacement therapy. In the low-risk group (three patients, one with renal replacement therapy), all patients survived, while in the intermediate-risk group (five patients, one with renal replacement therapy) three patients survived and two died. Additional severe comorbidities also contributed to mortality. CONCLUSIONS Every patient matching the screening criteria of acute renal failure, lactic acidosis and continued intake of metformin can be considered a potential MALA case. A risk score assessment which includes severe comorbidities may help to identify high-risk individuals and should be evaluated in larger studies.To prevent MALA, patients should be trained to immediately interrupt their own metformin use when showing signs of volume depletion. Physicians should be aware of the additional risk factors such as co-medication with diuretics, ACE (angiotensin converting enzyme) ACE inhibitors and NSAIDs (non steroidal anti inflammatory drugs).
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Affiliation(s)
- Philipp Schädle
- Centre of Internal Medicine I, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Stuttgart, Germany
| | - Otto Tschritter
- Centre of Internal Medicine I, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Stuttgart, Germany.,Emergency Department, Zollernalb Klinikum gGmbH, Balingen, Germany
| | - Monika Kellerer
- Centre of Internal Medicine I, Marienhospital Stuttgart, Vinzenz von Paul Kliniken, Stuttgart, Germany
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Taub ES, Hoffman RS, Manini AF. Incidence and risk factors for hyperlactatemia in ED patients with acute metformin overdose. Am J Emerg Med 2019; 37:2205-2208. [PMID: 30967322 PMCID: PMC9881186 DOI: 10.1016/j.ajem.2019.03.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/22/2019] [Accepted: 03/22/2019] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION The goals of this study are to describe clinical characteristics and risk factors for metabolic acidosis with hyperlactatemia in emergency department (ED) patients with acute metformin overdose. METHODS This was a secondary analysis of data from a retrospective observational cohort of adult ED patients presenting with acute drug overdose at two tertiary care hospitals over 5 years. The primary outcomes were: (1) hyperlactatemia, defined as a lactate concentration ≥ 2 mmol/L at any point during hospital admission and, (2) metformin associated lactic acidosis (MALA), defined as a lactate concentration ≥ 5 mmol/L and pH <7.35 at any point during hospital admission. RESULTS We screened 3739 acute overdoses; 2872 met eligibility, 56 self-reported metformin overdose (57% female, mean age 55.8). Of these, 39 had measured lactate values. There was a high incidence of hyperlactatemia (56.4%); MALA was less frequent (17.9%). There were no deaths. Low serum bicarbonate was an independent clinical risk factor for hyperlactatemia (adjusted p < 0.05). Acetaminophen co-exposure was an independent clinical risk factor for MALA (OR 24.40, 95% CI 1.6-376.4). CONCLUSIONS In ED patients with acute metformin overdose, initial hyperlactatemia is common but MALA is unusual. Acetaminophen co-exposure is a novel independent risk factor for the occurrence of MALA that deserves further investigation.
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Affiliation(s)
- Emily S Taub
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY, New York, USA.
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, NY, New York, USA.
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, The Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, NY, New York, USA.
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Abstract
Metformin is a lipophilic biguanide which inhibits hepatic gluconeogenesis and improves peripheral utilization of glucose. It is the first line pharmacotherapy for glucose control in patients with Type 2 diabetes due to its safety, efficacy and tolerability. Metformin exhibits pleotropic effects, which may have beneficial effects on a variety of tissues independent of glucose control. A potential anti-tumourigenic effect of metformin may be mediated by its role in activating AMP-kinase, which in turn inhibits mammalian target of rapamycin (mTOR). Non-AMPK dependent protective pathways may include reduction of insulin, insulin-like growth factor-1, leptin, inflammatory pathways and potentiation of adiponectin, all of which may have a role in tumourigenesis. A role in inhibiting cancer stem cells is also postulated. A number of large scale observational and cohort studies suggest metformin is associated with a reduced risk of a number of cancers, although the data is not conclusive. Recent randomised studies reporting use of metformin in treatment of cancer have revealed mixed results, and the results of much larger randomised trials of metformin as an adjuvant therapy in breast and colorectal cancers are awaited.
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Affiliation(s)
- Ritwika Mallik
- (a)International Training Fellow in Endocrinology and Diabetes, Department of Diabetes and Metabolism, Barts Health NHS Trust, London, UK
| | - Tahseen A Chowdhury
- Department of Diabetes and Metabolism, Barts and the London School of Medicine and Dentistry, London, UK.
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Umeda T, Minami T, Bartolomei K, Summerhill E. Metformin-Associated Lactic Acidosis: A Case Report. DRUG SAFETY - CASE REPORTS 2018; 5:8. [PMID: 29427160 PMCID: PMC5807253 DOI: 10.1007/s40800-018-0076-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 54-year-old woman with type 2 diabetes mellitus, hypertension, and peripheral vascular disease developed life-threatening lactic acidosis during treatment with metformin for type 2 diabetes. The woman received metformin at 1000 mg orally twice a day for type 2 diabetes. She presented to our emergency department with a 3-day history of severe watery diarrhea, nausea, and vomiting. Her grandson whom she cared for had gastroenteritis several days prior to the onset of her symptoms. She was confused and hypotensive with a blood pressure of 70/39 mmHg. Her initial laboratory findings were remarkable with an arterial blood gas pH 6.57, HCO[Formula: see text] 2 mEq/L, anion gap 30 mmol/L, and lactate 16.3 mmol/L. She was diagnosed with severe lactic acidosis. Metformin was discontinued. Upon arrival in the emergency department, she became unresponsive and experienced a pulseless electrical activity cardiac arrest. After resuscitation, her severe acidemia persisted despite aggressive intervention with volume resuscitation and vasopressors, leading to the initiation of renal replacement therapy. After multiple dialysis treatments, her severe acidemia resolved. Serum metformin concentration from presentation ultimately returned to 42 mcg/mL (therapeutic concentration: 1-2 mcg/mL). She was discharged from the hospital on day 15 without any neurologic complications. A Naranjo assessment score of 8 was obtained, indicating a probable relationship between the patient's lactic acidosis and her use of the suspect drug.
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Affiliation(s)
- Takehide Umeda
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, 420 Delaware Street SE, MMC 276, Minneapolis, MN, 55455, USA.
| | - Taro Minami
- Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA
| | - Keith Bartolomei
- Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA
| | - Eleanor Summerhill
- Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
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Jochmans S, Alphonsine JE, Chelly J, Vong LVP, Sy O, Rolin N, Ellrodt O, Monchi M, Vinsonneau C. Does metformin exposure before ICU stay have any impact on patients' outcome? A retrospective cohort study of diabetic patients. Ann Intensive Care 2017; 7:116. [PMID: 29198069 PMCID: PMC5712297 DOI: 10.1186/s13613-017-0336-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 11/04/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Impact of metformin exposure before ICU stay remains controversial. Metformin is thought to induce lactic acidosis and haemodynamic instability but may reduce ICU mortality. We evaluated its influence on outcome in diabetic patients admitted in the ICU and then compared two different populations based on the presence of septic shock. METHODS We conducted a retrospective cohort study in a 24-bed French ICU between October 2010 and December 2013, including all ICU-admitted diabetic patients. RESULTS Among 635 diabetic patients admitted during the study period, 131 (21%) were admitted with septic shock. Multivariate analysis showed no difference in hospital mortality in all metformin users (OR 0.75 [95% CI 0.44-1.28]; p = 0.29), except in the septic shock subgroup (OR 0.61; 95% CI [0.37-0.99]; p = 0.04) despite higher vasopressor dosages in the first hours after shock onset. Blood lactate level was higher in metformin users than in non-metformin users in all patients (p < 0.001), in septic shock patients (p < 0.001) and in patients without kidney injury (p < 0.001). Metformin users did not have more septic shock from unknown aetiology (p = 0.65) or unknown pathogen (p = 0.99). CONCLUSIONS Metformin use before admission to ICU did not affect in-hospital mortality. However, for patients with septic shock, mortality was lower, despite worse clinical presentation on admission. Blood lactate levels were always higher with or without septic shock and indifferent of kidney function.
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Affiliation(s)
- Sebastien Jochmans
- Département de Médecine Intensive et Unité de Recherche Clinique, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | | | - Jonathan Chelly
- Département de Médecine Intensive et Unité de Recherche Clinique, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Ly Van Phach Vong
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Oumar Sy
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Nathalie Rolin
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Olivier Ellrodt
- Département de Médecine Intensive, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
| | - Mehran Monchi
- Département de Médecine Intensive et Unité de Recherche Clinique, Groupe Hospitalier Sud Ile-de-France, Hôpital de Melun, 77000 Melun, France
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Barrella N, Eisenberg B, Simpson SN. Hypoglycemia and severe lactic acidosis in a dog following metformin exposure. Clin Case Rep 2017; 5:2097-2104. [PMID: 29225865 PMCID: PMC5715605 DOI: 10.1002/ccr3.1255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/01/2017] [Accepted: 10/06/2017] [Indexed: 01/18/2023] Open
Abstract
Hypoglycemia and lactic acidosis are rare complications with metformin use in humans. As metformin is not commonly used in veterinary medicine, severe adverse effects secondary to exposure are not known. Awareness of potentially life-threatening complications with metformin exposure is an important addition to the veterinary literature.
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Affiliation(s)
- Nicole Barrella
- Massachusetts Veterinary Referral HospitalWoburnMassachusetts01801USA
- Present address:
Bulger Veterinary HospitalNorth AndoverMassachusetts01845USA
| | - Beth Eisenberg
- Massachusetts Veterinary Referral HospitalWoburnMassachusetts01801USA
| | - Stephanie Nicole Simpson
- Massachusetts Veterinary Referral HospitalWoburnMassachusetts01801USA
- Present address:
VCA Roberts Animal HospitalHanoverMassachusetts02339USA
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Chowdhury TA, Srirathan D, Abraham G, Oei EL, Fan SL, McCafferty K, Yaqoob MM. Could metformin be used in patients with diabetes and advanced chronic kidney disease? Diabetes Obes Metab 2017; 19:156-161. [PMID: 27690331 DOI: 10.1111/dom.12799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/26/2016] [Accepted: 09/26/2016] [Indexed: 12/26/2022]
Abstract
Diabetes is an important cause of end stage renal failure worldwide. As renal impairment progresses, managing hyperglycaemia can prove increasingly challenging, as many medications are contra-indicated in moderate to severe renal impairment. Whilst evidence for tight glycaemic control reducing progression to renal failure in patients with established renal disease is limited, poor glycaemic control is not desirable, and is likely to lead to progressive complications. Metformin is a first-line therapy in patients with Type 2 diabetes, as it appears to be effective in reducing diabetes related end points and mortality in overweight patients. Cessation of metformin in patients with progressive renal disease may not only lead to deterioration in glucose control, but also to loss of protection from cardiovascular disease in a cohort of patients at particularly high risk. We advocate the need for further study to determine the role of metformin in patients with severe renal disease (chronic kidney disease stage 4-5), as well as patients on dialysis, or pre-/peri-renal transplantation. We explore possible roles of metformin in these circumstances, and suggest potential key areas for further study.
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Affiliation(s)
- Tahseen A Chowdhury
- Department of Diabetes, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - Danushan Srirathan
- Department of Diabetes, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - Georgi Abraham
- Department of Nephrology, Pondicherry Institute of Medical Sciences, Madras Medical Mission, Chennai, India
| | - Elizabeth L Oei
- Department of Nephrology, Singapore General Hospital, Singapore, Singapore
| | - Stanley L Fan
- Department of Nephrology, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - Kieran McCafferty
- Department of Nephrology, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
| | - M Magdi Yaqoob
- Department of Nephrology, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, London, UK
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Posma RA, Absalom AR, Touw DJ, van der Horst ICC, Nijsten MWN. Metformin and lactic acidosis during shock: just the tip of the iceberg? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:158. [PMID: 27246047 PMCID: PMC4888659 DOI: 10.1186/s13054-016-1333-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rene A Posma
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten W N Nijsten
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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12
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Retrospective analysis of lactic acidosis-related parameters upon and after metformin discontinuation in patients with diabetes and chronic kidney disease. Int Urol Nephrol 2016; 48:1305-1312. [PMID: 27102431 DOI: 10.1007/s11255-016-1288-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/09/2016] [Indexed: 01/22/2023]
Abstract
PURPOSE To investigate association between renal functions, lactic acid levels and acid-base balance in type 2 diabetes patients with chronic kidney disease under metformin treatment and after metformin discontinuation in a real-life setting. METHODS A total of 65 patients with diabetes (mean age 68.5 ± 8.9 years, 56.9 % females) in whom metformin treatment was discontinued due to reduced glomerular filtration rate (GFR) were included in this retrospective study. Data on patient demographics, metformin treatment and laboratory findings on the last day of metformin treatment and 2-3 weeks after metformin discontinuation including blood lactate and creatinine, estimated glomerular filtration rate (eGFR) and acid-base balance measurements in blood [pH, bicarbonate, base excess] were collected from medical records. The correlation of lactate levels with eGFR, blood pH and creatinine levels and changes in laboratory findings after metformin discontinuation were evaluated. RESULTS Before metformin discontinuation, hyperlactatemia was observed in 78.5 % of patients and metabolic acidosis in 36.9 % of patients, but none had lactic acidosis. Patients with normolactatemia and hyperlactatemia were similar in terms of metformin dosage and laboratory parameters. Lactate levels were not significantly correlated with serum creatinine (r = -0.14; p = 0.263) and eGFR (r = 0.11, p = 0.374). After metformin discontinuation, a significant decrease was observed in median lactate levels (from 2.20 to 1.85 mmol/L; p = 0.002). CONCLUSION In conclusion, our findings support the low risk of MALA among patients with mild-to-moderate renal impairment and the likelihood of metformin to be an innocent bystander without a pathogenic role in the lactic acidosis in most cases.
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DeFronzo R, Fleming GA, Chen K, Bicsak TA. Metformin-associated lactic acidosis: Current perspectives on causes and risk. Metabolism 2016; 65:20-9. [PMID: 26773926 DOI: 10.1016/j.metabol.2015.10.014] [Citation(s) in RCA: 310] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 12/11/2022]
Abstract
Although metformin has become a drug of choice for the treatment of type 2 diabetes mellitus, some patients may not receive it owing to the risk of lactic acidosis. Metformin, along with other drugs in the biguanide class, increases plasma lactate levels in a plasma concentration-dependent manner by inhibiting mitochondrial respiration predominantly in the liver. Elevated plasma metformin concentrations (as occur in individuals with renal impairment) and a secondary event or condition that further disrupts lactate production or clearance (e.g., cirrhosis, sepsis, or hypoperfusion), are typically necessary to cause metformin-associated lactic acidosis (MALA). As these secondary events may be unpredictable and the mortality rate for MALA approaches 50%, metformin has been contraindicated in moderate and severe renal impairment since its FDA approval in patients with normal renal function or mild renal insufficiency to minimize the potential for toxic metformin levels and MALA. However, the reported incidence of lactic acidosis in clinical practice has proved to be very low (<10 cases per 100,000 patient-years). Several groups have suggested that current renal function cutoffs for metformin are too conservative, thus depriving a substantial number of type 2 diabetes patients from the potential benefit of metformin therapy. On the other hand, the success of metformin as the first-line diabetes therapy may be a direct consequence of conservative labeling, the absence of which could have led to excess patient risk and eventual withdrawal from the market, as happened with earlier biguanide therapies. An investigational delayed-release metformin currently under development could potentially provide a treatment option for patients with renal impairment pending the results of future studies. This literature-based review provides an update on the impact of renal function and other conditions on metformin plasma levels and the risk of MALA in patients with type 2 diabetes.
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Affiliation(s)
- Ralph DeFronzo
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Kim Chen
- Elcelyx Therapeutics, Inc., San Diego, CA, USA
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Moioli A, Maresca B, Manzione A, Napoletano AM, Coclite D, Pirozzi N, Punzo G, Menè P. Metformin associated lactic acidosis (MALA): clinical profiling and management. J Nephrol 2016; 29:783-789. [PMID: 26800971 DOI: 10.1007/s40620-016-0267-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 01/09/2016] [Indexed: 12/20/2022]
Abstract
Metformin (MF) accumulation during acute kidney injury is associated with high anion gap lactic acidosis type B (MF-associated lactic acidosis, MALA), a serious medical condition leading to high mortality. Despite dose adjustment for renal failure, diabetic patients with chronic kidney disease (CKD) stage III-IV are at risk for rapid decline in renal function by whatever reason, so that MF toxicity might arise if the drug is not timely withdrawn. Sixteen consecutive patients were admitted to our Hospital's Emergency Department with clinical findings consistent with MALA. Fifteen had prior history of CKD, 60 % of them with GFR between 30 and 60 ml/min. Of these, 5 required mechanical ventilation and cardiovascular support; 3 promptly recovered renal function after rehydration, whereas 10 (62 %) required continuous veno-venous renal replacement treatment. SOFA and SAPS II scores were significantly related to the degree of lactic acidosis. In addition, lactate levels were relevant to therapeutic choices, since they were higher in dialyzed patients than in those on conservative treatment (11.92 mmol/l vs 5.7 mmol/l, p = 0.03). The overall death rate has been 31 %, with poorer prognosis for worse acidemia, as serum pH was significantly lower in non-survivors (pH 6.96 vs 7.16, p > 0.04). Our own data and a review of the literature suggest that aged, hemodynamically frail patients, with several comorbidities and CKD, are at greater risk of MALA, despite MF dosage adjustment. Moreover, renal replacement therapy rather than simple acidosis correction by administration of alkali seems the treatment of choice, based on eventual renal recovery and overall outcome.
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Affiliation(s)
- Alessandra Moioli
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Barbara Maresca
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Andrea Manzione
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | | | | | - Nicola Pirozzi
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Giorgio Punzo
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Paolo Menè
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy. .,Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy. .,UOC Nefrologia, A.O. Sant'Andrea, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
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15
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Abstract
Metabolic acidosis could emerge from diseases disrupting acid-base equilibrium or from drugs that induce similar derangements. Occurrences are usually accompanied by comorbid conditions of drug-induced metabolic acidosis, and clinical outcomes may range from mild to fatal. It is imperative that clinicians not only are fully aware of the list of drugs that may lead to metabolic acidosis but also understand the underlying pathogenic mechanisms. In this review, we categorized drug-induced metabolic acidosis in terms of pathophysiological mechanisms, as well as individual drugs’ characteristics.
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Affiliation(s)
- Amy Quynh Trang Pham
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Baylor Family Medicine Residency at Garland, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Li Hao Richie Xu
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Department of Physiology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
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16
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Adam WR, O'Brien RC. Comment on 'A justification for less restrictive guidelines on the use of metformin in stable chronic renal failure'. Diabet Med 2015; 32:1528. [PMID: 26248664 DOI: 10.1111/dme.12880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2015] [Indexed: 11/29/2022]
Affiliation(s)
- W R Adam
- Department of Rural Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - R C O'Brien
- Department of Medicine, Melbourne Medical School, University of Melbourne, Melbourne, Australia
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17
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Wypij JM. Pilot study of oral metformin in cancer-bearing cats. Vet Comp Oncol 2015; 15:345-354. [DOI: 10.1111/vco.12169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/20/2015] [Accepted: 08/10/2015] [Indexed: 01/26/2023]
Affiliation(s)
- J. M. Wypij
- Department of Veterinary Clinical Medicine; University of Illinois; Urbana IL USA
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18
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Kajbaf F, De Broe ME, Lalau JD. Therapeutic Concentrations of Metformin: A Systematic Review. Clin Pharmacokinet 2015; 55:439-59. [DOI: 10.1007/s40262-015-0323-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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19
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Abstract
Lactic acidosis occurs when lactate production exceeds its metabolism. There are many possible causes of lactic acidosis, and in any given patient, several causes may coexist. This Attending Rounds presents a case in point. Metformin's role in the pathogenesis of lactic acidosis in patients with diabetes mellitus is complex, as the present case illustrates. The treatment of lactic acidosis is controversial, except for the imperative to remedy its underlying cause. The use of sodium bicarbonate to treat the often alarming metabolic derangements may be quite efficacious in that regard but is of questionable benefit to patients. Renal replacement therapies (RRTs) have particular appeal in this setting for a variety of reasons, but their effect on clinical outcomes is untested.
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Affiliation(s)
- Lawrence S Weisberg
- Division of Nephrology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
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20
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Formiga F, Gómez-Huelgas R, Rodríguez Mañas L. [Differential characteristics of type 2 diabetes in the elderly. Role of dipeptidyl peptidase 4 inhibitors]. Rev Esp Geriatr Gerontol 2015; 51:44-51. [PMID: 26073221 DOI: 10.1016/j.regg.2015.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/21/2015] [Indexed: 12/30/2022]
Abstract
The prevalence of type 2 diabetes mellitus increases with age, reaching rates around 30% in those over 75 years. The type 2 diabetes mellitus in the elderly has different pathophysiological and clinical characteristics from those of the younger diabetic patient. Some differential aspects in this population are the lower life expectancy and the frequent comorbidity, frailty and associated disability. Avoiding hypoglycemia is a therapeutic priority, given their increased risk of severe hypoglycemia. It is a situation in which the benefits of intensive glycemic control are virtually non-existent, thus prevention of side effects of treatments becomes a priority. Therefore, the goals of glycemic control should be less stringent than in the general population (glycated hemoglobin>7%), and the drugs of choice should be those with a low risk of side effects (especially hypoglycemia) and well tolerated. Dipeptidyl peptidase 4 inhibitors (iDPP4) are particularly useful in this age group, either as a second drug added to metformin monotherapy, or as first line when metformin is contraindicated or not tolerated. In this article the evidence available on the efficacy and tolerance of different pharmacological options available in population over 70 years is reviewed.
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Affiliation(s)
- Francesc Formiga
- Programa de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, IDIBELL, ĹHospitalet de Llobregat, Barcelona, España.
| | - Ricardo Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España
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21
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Jones GC, Sainsbury CAR. Comment on 'A justification for less restrictive guidelines on the use of metformin in stable chronic renal failure'. Diabet Med 2015; 32:287. [PMID: 25385279 DOI: 10.1111/dme.12626] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 11/04/2014] [Indexed: 12/15/2022]
Affiliation(s)
- G C Jones
- Department of Diabetes, Gartnavel General Hospital, Glasgow, UK
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