Metformin-related lactic acidosis: Case report
Keywords:
Acidosis, lactic, Metformin, Sodium bicarbonate, Renal replacement therapy, Lactic acid
Abstract
Lactic acidosis is defined as the presence of pH <7.35, blood lactate >2.0 mmol/L and PaCO2 <42 mmHg. However, the definition of severe lactic acidosis is controversial. The primary cause of severe lactic acidosis is shock. Although rare, metformin-related lactic acidosis is associated with a mortality as high as 50%. The treatment for metabolic acidosis, including lactic acidosis, may be specific or general, using sodium bicarbonate, trihydroxyaminomethane, carbicarb or continuous haemodiafiltration. The successful treatment of lactic acidosis depends on the control of the aetiological source. Intermittent or continuous renal replacement therapy is perfectly justified, shock being the argument for deciding which modality to use. We report a case of a male patient presenting with metformin poisoning as a result of attempted suicide, who developed lactic acidosis and multiple organ failure. The critical success factor was treatment with continuous haemodiafiltration.
References
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30. Lalau JD. Lactic acidosis induced by metformin. Drug Saf. 2010;33:727-40.
31. Peters N, Jay N, Barraud D, Cravoisy A, Nace L, Bollaert PE, et al. Metformin-associated lactic acidosis in an intensive care unit. Crit Care. 2008;12:R149.
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33. Alivanis P, Giannikouris I, Paliuras C, Arvanitis A, Volanaki M, Zervos A. Metformin-associated lactic acidosis treated with continuous renal replacement therapy. Clin Ther. 2006;28:396-400.
34. Calello DP, Liu KD, Wiegand TJ, Roberts DM, Lavergne V, Gosselin S, et al. Extracorporeal treatment for metformin poisoning: systematic review and recommendations from the extracorporeal treatments in poisoning workgroup. Crit Care Med. 2015;43:1716-30.
35. Friesecke S, Abel Peter, Roser Markus, Felix SB, Runge S. Outcome of severe lactic acidosis associated with metformin accumulation. Crit Care. 2010;14:R226.
36. Sänchez-Diaz JS, Martinez-Rodriguez EA, Mendez-Rubio LP, Peniche-Moguel KG, Huanca-Pacaje JM, Lopez-Guzmän C, et al. Equilibrio äcido-base. Puesta al dia. Teoria de Henderson-Hasselbalch. Med Int Mex. 2016;32:646-60.
37. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43:304-77.
38. Velissaris D, Karamouzos V, Ktenopoulos N, Pierrakos C, Karanikolas M. The use of sodium bicarbonate in the treatment of acidosis in sepsis: a literature update on a long term debate. Crit Care Res Pract. 2015;2015:605830.
39. Morris CG, Low J. Metabolic acidosis in the critically ill: part 2. Causes and treatment. Anaesthesia. 2008;63:396-411.
40. Adeva-Andany MM, Fernändez-Fernändez C, Mourifio-Bayolo D, Castro-Quintela E, Dominguez-Monter A. Sodium bicarbonate therapy in patients with metabolic acidosis. Sci World J. 2014, 627673.
41. Palazzo MGA. Sodium bicarbonate - the bicarbonate challenge test in metabolic acidosis: a practical consideration. Curr Anaesth Crit Care. 2009;20:259-63. [
2. Morris CG, Low J. Metabolic acidosis in the critically ill: part 1. Classification and pathophysiology. Anaesthesia. 2008;63:294-301.
3. Kraut JA, Kurtz I. Use of base in the treatment of acute severe organic acidosis by nephrologists and critical car physicians: results of an online survey. Clin Exp Nephrol. 2006;10: 111-7.
4. Noritomi DT, Soriano FG, Kellum JA, Cappi SB, Biselli PJ, Liborio AB, et al. Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med. 2009;37:2733-9.
5. Smith I, Kuma P, Molloy S, Rhodes A, Newman PJ, Grounds RM, et al. Base excess and lactate as prognostic indicators for patients admitted to intensive care. Intensive Care Med. 2001;27:74-83.
6. Kirpichnikov D, McFarlane SI, Sowers JR. Metformin: an update. Ann Intern Med. 2002;137:25-33.
7. Seidowsky A, Nseir S, Houdret N, Fourrier F. Metformin-associated lactic acidosis: a prognostic and therapeutic study. Crit Care Med. 2009;37:2191-6.
8. Roussel R, Travert F, Pasquet B, Wilson PW, Smith SC Jr, Goto S, et al. Metformin use and mortality among patients with diabetes and atherothrombosis. Arch Intern Med. 2010;170:1892-9.
9. Friesecke S, Abel P, Roser M, Felix SF, Runge S. Outcome of severe lactic acidosis associated with metformin accumulation. Crit Care. 2010;14:R226.
10. Vernon C, Le Tourneau JL. Lactic acidosis: recognition, kinetics, and associated prognosis. Crit Care Clin. 2010;26:255-83.
11. Reddy AJ, Lam SW, Bauer SR, Guzman JA. Lactic acidosis: clinical implications and management strategies. Cleve Clin J Med. 2015;82:615-24.
12. Seheult J, Fitzpatrick G, Boran G. Lactic acidosis: an update. Clin Chem Lab Med. 2017;55:322-33.
13. Sänchez-Diaz JS, Meneses-Olguin C, Monares-Zepeda E, Torres-Gomez A, Aguirre-Sänchez J, Franco-Granillo J. La diferencia de iones fuertes (DIF) calculada por el metodo de Fencl-Stewart simplificado es un predictor de mortalidad en pacientes con choque septico. Arch Med Urgen Mexico. 2014;6:5-11.
14. Cohen RD, Woods HF. The clinical presentation and classification of lactic acidosis. In: Cohen RD, Woods HF, editors. Clinical and biochemical aspects of lactic acidosis. Oxford: Blackwell Scientific; 1976.
15. Ruiz JP, Singh AK, Hart P, Type B. lactic acidosis secondary to malignancy: case report, review of published cases, insights into pathogenesis, and prospects for therapy. Sci World J. 2011;11:1316-24.
16. Caton PW, Nayuni NK, Kieswich J, Khan NQ, Yaqoob MM, Corder R. Metformin suppresses hepatic gluconeogenesis through induction of SIRT1 and GCN5. J Endocrinol. 2010;205:97-106.
17. Leverve XM, Guigas B, Detaille D, Batandier C, Koceir EA, Chauvin C, et al. Mitochondrial metabolism and type-2 diabetes: a specific target of metformin. Diabetes Metab. 2003;29 Pt 2, 6S88-94.
18. Owen MR, Doran E, Halestrap AP. Evidence that metformin exerts its anti-diabetic effects through inhibition of complex 1 of the mitochondrial respiratory chain. Biochem J. 2000;348 Pt 3:607-14.
19. Luengo A, Sullivan LB, Vander Heiden MG. Understanding the complex-I-ty of metformin action: limiting mitochondrial respiration to improve cancer therapy. BMC Biol. 2014;12:82.
20. Bakker J, Nijsten MW, Jancen TC. Clinical use of lactate monitoring in critically ill patients. Ann Intensive Care. 2013;3:12.
21. Rena G, Pearson ER, Sakamoto K. Molecular mechanism of action of metformin: old or new insight? Diabetologia. 2013;56:1898-906.
22. Zheng J, Woo SL, Hu X, Botchlett R, Chen L, Huo Y, et al. Metformin and metabolic diseases: a focus on hepatic aspects. Front Med. 2015;9:173-86.
23. Graham GG, Punt J, Arora M, Day RO, Doogue MP, Duong JK, et al. Clinical pharmacokinetics of metformin. Clin Pharmacokinet. 2011;50:81-98.
24. Lalau JD, Lacroix C. Measurement of metformin concentration in erythrocytes: clinical implications. Diabetes Obes Metab. 2003;5:93-8.
25. Sirtori CR, Franceschini G, Galli-Kienle M, Cighetti G, Galli G, Bondioli, et al. Disposition of metformin (N,N-dimethylbiguanide) in man. Clin Pharmacol Ther. 1978;24:683-93.
26. Scheen AJ. Clinical pharmacokinetics of metformin. Clin Pharmacokinet. 1996;30:359-71.
27. Pentikäinen PJ, Neuvonen PJ, Penttilä A. Pharmacokinetics of metformin after intravenous and oral administration to man. Eur J Clin Pharmacol. 1979;16:195-202.
28. Lalau JD, Andrejak M, Moriniere P,Coevoet B, Debussche X, Westeel PF, et al. Hemodialysis in the treatment of lactic acidosis in diabetics treated by metformin: a study of metformin elimination. Int J Clin Pharmacol Ther Toxicol. 1989;27:285-8.
29. Kim MJ, Han JY, Shin JY, Kim SI, Lee JM, Hong S, et al. Metformin-associated lactic acidosis: predisposing factors and outcome. Endocrinol Metab. 2015;30:78-83.
30. Lalau JD. Lactic acidosis induced by metformin. Drug Saf. 2010;33:727-40.
31. Peters N, Jay N, Barraud D, Cravoisy A, Nace L, Bollaert PE, et al. Metformin-associated lactic acidosis in an intensive care unit. Crit Care. 2008;12:R149.
32. De Fronzo R, Fleming GA, Chen K, Bicsak TA. Metformin-associated lactic acidosis: current perspectives on causes and risk. Metabolism. 2016;65:20-9.
33. Alivanis P, Giannikouris I, Paliuras C, Arvanitis A, Volanaki M, Zervos A. Metformin-associated lactic acidosis treated with continuous renal replacement therapy. Clin Ther. 2006;28:396-400.
34. Calello DP, Liu KD, Wiegand TJ, Roberts DM, Lavergne V, Gosselin S, et al. Extracorporeal treatment for metformin poisoning: systematic review and recommendations from the extracorporeal treatments in poisoning workgroup. Crit Care Med. 2015;43:1716-30.
35. Friesecke S, Abel Peter, Roser Markus, Felix SB, Runge S. Outcome of severe lactic acidosis associated with metformin accumulation. Crit Care. 2010;14:R226.
36. Sänchez-Diaz JS, Martinez-Rodriguez EA, Mendez-Rubio LP, Peniche-Moguel KG, Huanca-Pacaje JM, Lopez-Guzmän C, et al. Equilibrio äcido-base. Puesta al dia. Teoria de Henderson-Hasselbalch. Med Int Mex. 2016;32:646-60.
37. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017;43:304-77.
38. Velissaris D, Karamouzos V, Ktenopoulos N, Pierrakos C, Karanikolas M. The use of sodium bicarbonate in the treatment of acidosis in sepsis: a literature update on a long term debate. Crit Care Res Pract. 2015;2015:605830.
39. Morris CG, Low J. Metabolic acidosis in the critically ill: part 2. Causes and treatment. Anaesthesia. 2008;63:396-411.
40. Adeva-Andany MM, Fernändez-Fernändez C, Mourifio-Bayolo D, Castro-Quintela E, Dominguez-Monter A. Sodium bicarbonate therapy in patients with metabolic acidosis. Sci World J. 2014, 627673.
41. Palazzo MGA. Sodium bicarbonate - the bicarbonate challenge test in metabolic acidosis: a practical consideration. Curr Anaesth Crit Care. 2009;20:259-63. [
How to Cite
1.
Sanchez-Díaz JS, Monares-Zepeda E, Martinez-Rodríguez EA, Cortes-Román JS, Torres-Aguilar O, Peniche-Moguel KG, et al. Metformin-related lactic acidosis: Case report. Colomb. J. Anesthesiol. [Internet]. 2017 Oct. 1 [cited 2024 Apr. 24];45(4):353–359. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/576
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Published
2017-10-01
How to Cite
1.
Sanchez-Díaz JS, Monares-Zepeda E, Martinez-Rodríguez EA, Cortes-Román JS, Torres-Aguilar O, Peniche-Moguel KG, et al. Metformin-related lactic acidosis: Case report. Colomb. J. Anesthesiol. [Internet]. 2017 Oct. 1 [cited 2024 Apr. 24];45(4):353–359. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/576
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