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Simon EL, Sherry AC, Rabinowitz J. Metformin-Associated Lactic Acidosis-Is This on Your Radar? J Emerg Med 2024; 66:e530-e533. [PMID: 38423865 DOI: 10.1016/j.jemermed.2023.11.017] [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: 08/08/2023] [Revised: 10/11/2023] [Accepted: 11/23/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Metformin is a biguanide hyperglycemic agent used to manage non-insulin-dependent diabetes mellitus. Adverse reactions include mainly mild gastrointestinal adverse effects, but severe complications, such as metformin-associated lactic acidosis (MALA) can occur. Metformin is excreted renally and, therefore, not recommended in patients with renal impairment. The reported incidence of MALA is 3 cases per 100,000 patient-years. CASE REPORT A 79-year-old woman with a complex medical history, including end-stage renal disease on dialysis and type 2 diabetes, presented to the emergency department (ED) for altered mental status. Prior to arrival, she was found to be hypoglycemic. Her laboratory results were significant for creatinine of 6.56 mg/dL and an anion gap of 52 mmol/L. The venous blood gas revealed a venous pH of 6.857 [reference range (7.32-7.43)], pCO2 of 15.9 mm Hg (40.6-60 mm Hg), HCO3 of 2.7 mmol/L (21-30 mmol/L), lactate of 27 mmol/L (0.5-2 mmol/L), and ammonia of 233 µmol/L. The patient was dialyzed emergently in the ED; repeat laboratory test results showed blood urea nitrogen of 10 mg/dL, creatinine of 1.65 mg/dL, carbon dioxide of 26 mmol/L, and anion gap of 13 mmol/L. The repeat ammonia was 16 µmol/L. The patient's metabolic encephalopathy resolved, and she was discharged home on hospital day 3. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: MALA has a high mortality rate (36%). Laboratory markers have not been found to be a reliable predictor of mortality. Sodium bicarbonate is controversial, but a pH < 7.15 indicates consideration of its use. A pH < 7.1 and a lactate level > 20 mmol/L indicate the need for emergent hemodialysis. Prompt recognition and management in the ED with early hemodialysis can result in good patient outcomes, with a return to their baseline function despite severe laboratory findings.
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Affiliation(s)
- Erin L Simon
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio
| | | | - Jeffrey Rabinowitz
- Department of Emergency Medicine, Cleveland Clinic Akron General, Akron, Ohio
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Abaleka FI, Bedanie G, Olavarria Bernal D, Yewedalsew SF, Seen T. Type B Lactic Acidosis: A Very Rare but Fatal Complication of Gastrointestinal Solid Tumor. Cureus 2024; 16:e56788. [PMID: 38650771 PMCID: PMC11034928 DOI: 10.7759/cureus.56788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024] Open
Abstract
Type B lactic acidosis, secondary to solid cancer, is very rare. It is mostly seen in patients with hematological malignancies. Although its exact pathogenesis is unknown, it is believed to be caused by overproduction and the inability of tumor cells to remove lactate. In the last 26 years, a systematic review of the literature only identified two previous reports of colorectal cancer-related type B lactic acidosis. Here, we report the third case of severe type B lactic acidosis due to stage IV colorectal with liver metastasis. Besides, this case is unique in that serum lactate levels reaching as high as 24 mmol/L were not reported in association with colorectal cancer. In most cases, the prognosis is still very poor because there are no standardized treatment recommendations. Early chemotherapy is still the only intervention that provides some survival benefits.
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Affiliation(s)
- Fuad I Abaleka
- Internal Medicine, Covenant Medical Center, Lubbock, USA
| | - Genanew Bedanie
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | | | - Selome F Yewedalsew
- Internal Medicine, State University of New York (SUNY) Downstate Health Science, New York, USA
| | - Tasur Seen
- Gastroenterology, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital, Elmhurst, USA
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Garcia Ruiz PJ, Feliz LD, Feliz CE, Sanchez IL, Fernandez AA, Kelly FB, Tiebas MJT, del Val J, Vinagre IN. The enduring enigma of sporadic chorea: A single center case series. Tremor Other Hyperkinet Mov (N Y) 2023; 13:33. [PMID: 37692071 PMCID: PMC10487123 DOI: 10.5334/tohm.800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/24/2023] [Indexed: 09/12/2023] Open
Abstract
Chorea can have a wide variety of causes including neurodegenerative, pharmacological, structural, metabolic, infectious, immunologic and paraneoplastic processes. We reviewed the clinical records of patients with apparently sporadic choreic movements and no relevant family history, who presented to our neurology department (Hospital Fundación Jimenez Diaz) between 1991 and 2022. We detected 38 cases of apparent sporadic chorea (ASC); Our analysis revealed 5 cases of genetic chorea (including 3 cases with Huntington's disease) while 6 cases were autoimmune/hematological; 6 drug-related chorea, 5 metabolic-vascular, 5 due to miscellaneous conditions and 4 were of mixed etiology. No clear etiology was identified in 8 cases. The differential diagnosis of ASC is extensive and challenging. Highlights Chorea can have a wide variety of genetic and sporadic causesWe reviewed the clinical records of patients with apparently sporadic chorea (ASC), who presented to our neurology department over the last 30 yearsWe detected 38 cases of apparent ASC; Our analysis revealed a wide array of different sporadic conditions and 5 cases of genetic choreaThe differential diagnosis of ASC is extensive and challenging.
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Affiliation(s)
| | - Lola Diaz Feliz
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | - Cici E. Feliz
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
| | | | | | | | | | - Javier del Val
- Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain
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Nzomessi D, Massie E, Gariani K, Giraud R, Meyer P. Combined lactic acidosis and ketoacidosis in a female diabetic patient with severe heart failure. Cardiovasc Endocrinol Metab 2023; 12:e0287. [PMID: 37424794 PMCID: PMC10325753 DOI: 10.1097/xce.0000000000000287] [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: 11/30/2022] [Accepted: 06/14/2023] [Indexed: 07/11/2023]
Abstract
SGLT2i are now recommended in a wide spectrum of indications including type 2 diabetes (T2DM), heart failure, and chronic kidney disease. This medication class is now available in combination with metformin, which is still a fundamental treatment in patients with T2DM. Despite excellent proven safety profile for both drugs, the expanding use of these agents in clinical practice may lead to an increased incidence of rare side effects, like metformin-associated lactic acidosis (MALA) and euglycemic diabetic ketoacidosis (EDKA), which can be life-threatening. A 58-year-old woman with T2DM and severe heart failure treated by metformin and empagliflozin developed progressive EDKA triggered by fasting that was also complicated by severe acute renal failure and MALA. She was successfully treated with intermittent hemodialysis. This case report highlights the importance of the recognition of rare, but very serious adverse effects due to combined metformin and SGLT2i therapy.
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Affiliation(s)
| | | | - Karim Gariani
- Division of Endocrinology, Diabetology, Nutrition and Therapeutic Education
| | - Raphael Giraud
- Division of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
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Nzenwa IC, Berquist M, Brenner TJ, Ansari A, Al-Fadhl HD, Aboukhaled M, Patel SS, Peck EE, Al-Fadhl MD, Thomas AV, Zackariya N, Walsh MM, Bufill JA. Type B Lactic Acidosis in a Patient with Mantle Cell Lymphoma. Case Rep Crit Care 2023; 2023:7021123. [PMID: 37621746 PMCID: PMC10447056 DOI: 10.1155/2023/7021123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/23/2023] [Accepted: 07/29/2023] [Indexed: 08/26/2023] Open
Abstract
Type B lactic acidosis is an uncommon medical emergency in which acid production overwhelms hepatic clearance. This specific etiology of lactic acidosis occurs without organ hypoperfusion and has been most commonly described in patients with hematologic malignancies but also in patients with solid tumors. The mechanism by which cancer cells switch their glucose metabolism toward increasingly anaerobic glycolytic phenotypes has been described as the "Warburg effect." Without treating the underlying malignancy, the prognosis for patients diagnosed with malignancy-related type B lactic acidosis is extremely poor. Here, we present a case of a 66-year-old male who was diagnosed with type B lactic acidosis secondary to mantle cell lymphoma. Bicarbonate drip was started to correct the lactic acidosis. The patient was also immediately treated with rituximab chemotherapy combined with rasburicase to avoid the hyperuricemia associated with tumor lysis syndrome. He responded to the early treatment and was discharged with normal renal function. Type B lactic acidosis secondary to hematologic malignancy is important to recognize. In order to successfully treat this syndrome, early diagnosis and simultaneous treatment of the imbalance of lactic acid levels and the underlying malignancy are necessary.
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Affiliation(s)
| | | | - Toby J. Brenner
- Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
| | - Aida Ansari
- Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
| | | | | | | | - Ethan E. Peck
- Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
| | - Mahmoud D. Al-Fadhl
- Indiana University School of Medicine South Bend Campus, Notre Dame, Indiana, USA
| | - Anthony V. Thomas
- Indiana University School of Medicine South Bend Campus, Notre Dame, Indiana, USA
| | - Nuha Zackariya
- Indiana University School of Medicine South Bend Campus, Notre Dame, Indiana, USA
| | - Mark M. Walsh
- Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
- Indiana University School of Medicine South Bend Campus, Notre Dame, Indiana, USA
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Hu M, Chen Y, Ma T, Jing L. Repurposing Metformin in hematologic tumor: State of art. Curr Probl Cancer 2023; 47:100972. [PMID: 37364455 DOI: 10.1016/j.currproblcancer.2023.100972] [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: 01/21/2023] [Revised: 02/19/2023] [Accepted: 04/25/2023] [Indexed: 06/28/2023]
Abstract
Metformin is an ancient drug for the treatment of type 2 diabetes, and many studies now suggested that metformin can be used as an adjuvant drug in the treatment of many types of tumors. The mechanism of action of metformin for tumor treatment mainly involves: 1. activation of AMPK signaling pathway 2. inhibition of DNA damage repair in tumor cells 3. downregulation of IGF-1 expression 4. inhibition of chemoresistance and enhancement of chemotherapy sensitivity in tumor cells 5. enhancement of antitumor immunity 6. inhibition of oxidative phosphorylation (OXPHOS). Metformin also plays an important role in the treatment of hematologic tumors, especially in leukemia, lymphoma, and multiple myeloma (MM). The combination of metformin and chemotherapy enhances the efficacy of chemotherapy, and metformin reduces the progression of monoclonal gammopathy of undetermined significance (MGUS) to MM. The purpose of this review is to summarize the anticancer mechanism of metformin and the role and mechanism of action of metformin in hematologic tumors. We mainly summarize the studies related to metformin in hematologic tumors, including cellular experiments and animal experiments, as well as controlled clinical studies and clinical trials. In addition, we also focus on the possible side effects of metformin. Although a large number of preclinical and clinical studies have been performed and the role of metformin in preventing the progression of MGUS to MM has been demonstrated, metformin has not been approved for the treatment of hematologic tumors, which is related to the adverse effects of its high-dose application. Low-dose metformin reduces adverse effects and has been shown to alter the tumor microenvironment and enhance antitumor immune response, which is one of the main directions for future research.
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Affiliation(s)
- Min Hu
- Department of Hematology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, China
| | - Yan Chen
- Department of Hematology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, China
| | - Tao Ma
- Department of Hematology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, China.
| | - Li Jing
- Department of Hematology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, China.
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Inman B, Maddry JK, Ng PC, Koyfman A, Long B. High risk and low prevalence diseases: Toxic alcohol ingestion. Am J Emerg Med 2023; 67:29-36. [PMID: 36796238 DOI: 10.1016/j.ajem.2023.01.048] [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: 11/07/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Toxic alcohol ingestion is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of toxic alcohol ingestion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Toxic alcohols include ethylene glycol, methanol, isopropyl alcohol, propylene glycol, and diethylene glycol. These substances can be found in several settings including hospitals, hardware stores, and the household, and ingestion can be accidental or intentional. Toxic alcohol ingestion presents with various degrees of inebriation, acidemia, and end-organ damage depending on the substance. Timely diagnosis is critical to prevent irreversible organ damage or death and is based primarily on clinical history and consideration of this entity. Laboratory evidence of toxic alcohol ingestion includes worsening osmolar gap or anion-gap acidemia and end organ injury. Treatment depends on the ingestion and severity of illness but includes alcohol dehydrogenase blockade with fomepizole or ethanol and special considerations for the initiation of hemodialysis. CONCLUSIONS An understanding of toxic alcohol ingestion can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Brannon Inman
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Joseph K Maddry
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Patrick C Ng
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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8
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Xia Y, Zhu X, Wu C. Metformin-associated severe lactic acidosis combined with multi-organ insufficiency induced by infection with Aeromonas veronii: A case report. Medicine (Baltimore) 2023; 102:e32659. [PMID: 36637931 PMCID: PMC9839295 DOI: 10.1097/md.0000000000032659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Lactic acidosis is a disease in which lactic acid accumulates in the blood and causes acidosis in the patient. The criteria for diagnosis are a lactate level of >2 mmol/L in the blood and a blood pH of <7.2. PATIENT CONCERNS A 72-year-old Asian female with a history of diabetes for 20+ years was admitted to the hospital with the chief complaint of "dry mouth, polydipsia for 20+ years, loss of appetite for 5+ days, vomiting for 1-day." She was admitted with a blood gas pH of 6.795, and a lactate level of >30 mmol/L. DIAGNOSES Type 2 diabetes mellitus with lactic acidosis, ketoacidosis, chronic renal insufficiency, hypertensive disease, and coronary arteriosclerotic heart disease. INTERVENTIONS She was treated with symptomatic rehydration and ketone reduction immediately, but then became unconscious and was admitted to the intensive care unit, where she was administered symptomatic support and continuous renal replacement therapy. As the blood culture showed Aeromonas veronii, she was administered a sensitive antibiotic in conjunction. OUTCOMES However, after achieving a stable internal environment and good infection control, the patient's family decided to discontinue treatment because of persistent heart failure with acute exacerbation of chronic renal insufficiency complicated by gastrointestinal bleeding. LESSONS Lactic acidosis has low incidence, poor prognosis, and high morbidity and mortality rates. Special attention should be paid to infection-induced acidosis, especially in patients with combined multi-organ insufficiency. Early diagnosis and active management can improve the patient prognosis.
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Affiliation(s)
- Yu Xia
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaofeng Zhu
- Department of Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Changxue Wu
- Department of Anesthesiology, School of Clinical Medicine, Southwest Medical University, Luzhou, Sichuan Province, China
- * Correspondence: Changxue Wu, Department of Anesthesiology, School of Clinical Medicine, Southwest Medical University, No. 5, Section 3, Zhongshan Road, Luzhou, Sichuan Province 646000, China (e-mail: )
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Yang CC, Weng SF, Tseng KL, Ho CH. Clinical presentations and prognosis of metformin-associated lactic acidosis patients in the intensive care unit: A 20-year survey. Medicine (Baltimore) 2022; 101:e29918. [PMID: 35801742 PMCID: PMC9259133 DOI: 10.1097/md.0000000000029918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
METHODS We retrospectively analyzed 82 adult patients with MALA admitted to the ICU over 20 years. The association between the clinical parameters and mortality post-MALA was estimated using logistic regression analysis. RESULTS Patients with MALA admitted to the ICU presented with clinical symptoms mainly associated with the head (40.24%), chest (41.46%), and abdomen (35.37%). Additionally, the PLL distribution significantly varied with age, APACHE II = Acute Physiology and Chronic Health Evaluation II (APACHE II) score, various laboratory parameters like nadir arterial bicarbonate level, multiple treatment modalities such as renal replacement therapy, and mortality. The overall mortality rate was 17.07%. After adjustment of age and gender, the significant predictors of mortality were APACHE II score, PLL, vasoactive support, ventilator support, and cardiopulmonary resuscitation. CONCLUSIONS Despite MALA being a rare event, it is necessary to evaluate its clinical characteristics, especially the associated PLL and mortality. In the current study, higher levels of APACHE II score and PLL show a greater likelihood of mortality in MALA patients.
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Affiliation(s)
- Chun-Chieh Yang
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Shih-Feng Weng
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuei-Ling Tseng
- Department of Respiratory Therapy, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
- *Correspondence: Chung-Han Ho, Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan. (e-mail: )
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Vieira IH, Petrova M, Moura JP. Does the Same Hyperlactatemia Cut-Off in the Context of Acute Diseases Hold the Same Meaning in Diabetes Mellitus? Cureus 2022; 14:e25163. [PMID: 35747014 PMCID: PMC9206834 DOI: 10.7759/cureus.25163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background Hyperlactatemia is defined by a lactate concentration of >2 mmol/L, and a lactate concentration of above >4 mmol/L is commonly used to define severe hyperlactatemia. It is a common disorder in critically ill patients and is associated with adverse prognosis. Diabetes mellitus(DM) can also be associated with increased lactate levels at baseline. In this study, we aimed to document the development of severe hyperlactatemia in acute situations among patients with and without DM, to analyze potential contributors to lactate elevation and their impact on mortality, and to analyze whether lactate concentrations of >4 mmol/L have equal prognostic significance in patients with and without DM. Methodology A retrospective, cross-sectional study was performed among patients admitted to our internal medicine wards in the context of acute disease with lactate concentrations of ≥2 mmol/L. Data were collected regarding age, sex, highest lactate concentrations, cause of hyperlactatemia, DM, and mortality. Statistical analysis was performed using SPSS version 23. Results In total, 151 patients with lactate levels of ≥2 mmol/L were analyzed. The mean age of the patients was 78.2 ± 14.9 years, and 55% of the patients were female. Overall, 55.6% of the patients had DM, as well as higher lactatemia of 6.3 ± 3.4 mmol/L (vs 5.1 ± 3.2 in non-DM patients, p = 0.003), with the majority reaching values of >4 mmol/L (vs 34.8% in non-DM patients). When potential contributors to the development of severe hyperlactatemia (lactate >4 mmol/L) were analyzed in DM patients, metformin consumption concomitantly with factors potentiating its accumulation, sepsis/septic shock, ischemia, and neoplasia were the most frequently identified contributors. In non-DM patients, the three former factors were also the most frequently reported. The 30-day mortality rate was 25.82%, with deceased patients also displaying a higher lactatemia of 6.5 ± 3.2 mmol/L (vs. 5.5 ± 3.3 mmol/L in patients who survived) (p = 0.037). In multivariate analysis, lactate values of >4 mmol/L were an independent predictor of mortality in the entire sample and in the subgroup without DM, but not in DM patients. Conclusions In our sample, patients with DM had higher lactate levels than non-DM patients. Our analysis raises the possibility that the same lactate values may not have equal capacity to assess prognosis in acute situations in patients with and without DM. Large-scale studies are needed to optimize cut-off points for lactatemia in patients with high baseline values, such as DM patients.
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Feng J, Wang X, Ye X, Ares I, Lopez-Torres B, Martínez M, Martínez-Larrañaga MR, Wang X, Anadón A, Martínez MA. Mitochondria as an important target of metformin: The mechanism of action, toxic and side effects, and new therapeutic applications. Pharmacol Res 2022; 177:106114. [DOI: 10.1016/j.phrs.2022.106114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/21/2022] [Accepted: 02/01/2022] [Indexed: 12/25/2022]
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PGC-1α inhibits the NLRP3 inflammasome via preserving mitochondrial viability to protect kidney fibrosis. Cell Death Dis 2022; 13:31. [PMID: 35013155 PMCID: PMC8748677 DOI: 10.1038/s41419-021-04480-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/03/2021] [Accepted: 12/14/2021] [Indexed: 12/11/2022]
Abstract
The NLRP3 inflammasome is activated by mitochondrial damage and contributes to kidney fibrosis. However, it is unknown whether PGC-1α, a key mitochondrial biogenesis regulator, modulates NLRP3 inflammasome in kidney injury. Primary renal tubular epithelial cells (RTECs) were isolated from C57BL/6 mice. The NLRP3 inflammasome, mitochondrial dynamics and morphology, oxidative stress, and cell injury markers were examined in RTECs treated by TGF-β1 with or without Ppargc1a plasmid, PGC-1α activator (metformin), and siPGC-1α. In vivo, adenine-fed and unilateral ureteral obstruction (UUO) mice were treated with metformin. In vitro, TGF-β1 treatment to RTECs suppressed the expressions of PGC-1α and mitochondrial dynamic-related genes. The NLRP3 inflammasome was also activated and the expression of fibrotic and cell injury markers was increased. PGC-1α induction with the plasmid and metformin improved mitochondrial dynamics and morphology and attenuated the NLRP3 inflammasome and cell injury. The opposite changes were observed by siPGC-1α. The oxidative stress levels, which are inducers of the NLRP3 inflammasome, were increased and the expression of TNFAIP3, a negative regulator of NLRP3 inflammasome regulated by PGC-1α, was decreased by TGF-β1 and siPGC-1α. However, PGC-1α restoration reversed these alterations. In vivo, adenine-fed and UUO mice models showed suppression of PGC-1α and TNFAIP3 and dysregulated mitochondrial dynamics. Moreover, the activation of oxidative stress and NLRP3 inflammasome, and kidney fibrosis were increased in these mice. However, these changes were significantly reversed by metformin. This study demonstrated that kidney injury was ameliorated by PGC-1α-induced inactivation of the NLRP3 inflammasome via modulation of mitochondrial viability and dynamics.
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Vieira IH, Barros LM, Baptista CF, Rodrigues DM, Paiva IM. Recommendations for Practical Use of Metformin, a Central Pharmacological Therapy in Type 2 Diabetes. Clin Diabetes 2022; 40:97-107. [PMID: 35221479 PMCID: PMC8865803 DOI: 10.2337/cd21-0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Inês H. Vieira
- Coimbra Hospital and University Centre, Coimbra, Portugal
- Corresponding author: Inês H. Vieira,
| | | | | | - Dírcea M. Rodrigues
- Coimbra Hospital and University Centre, Coimbra, Portugal
- University of Coimbra, Coimbra, Portugal
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Rashid U, Marra EM, Tran VH. Bilateral Ureteral Obstruction Causing Acute Kidney Injury and Resultant Metformin Toxicity. Cureus 2021; 13:e19635. [PMID: 34956761 PMCID: PMC8675570 DOI: 10.7759/cureus.19635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/20/2022] Open
Abstract
A 55-year-old male with a past medical history of type 2 diabetes mellitus on metformin presented to the emergency department (ED) due to shortness of breath and three days of lumbar back pain. Workup revealed bilateral obstructing ureteral stones causing bilateral hydronephrosis, acute kidney injury (AKI), and profound anion gap metabolic acidosis due to concomitant metformin-associated lactic acidosis (MALA). In the ED, the patient developed profound shock refractory to fluid resuscitation, requiring initiation of multiple vasopressors, and stress dose steroids. He was transferred to the interventional radiology suite for bilateral percutaneous nephrostomy tubes and only improved once continuous renal replacement therapy was initiated.
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Affiliation(s)
- Umar Rashid
- Emergency Medicine, Graduate Medical Education, Aventura Hospital and Medical Center, Aventura, USA
| | - Erin M Marra
- Emergency Medicine, Graduate Medical Education, Aventura Hospital and Medical Center, Aventura, USA
| | - Vu H Tran
- Emergency Medicine, Graduate Medical Education, Aventura Hospital and Medical Center, Aventura, USA
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Thapa M, Sung R, Heo YS. A Dual Electrode Biosensor for Glucose and Lactate Measurement in Normal and Prolonged Obese Mice Using Single Drop of Whole Blood. BIOSENSORS 2021; 11:bios11120507. [PMID: 34940264 PMCID: PMC8699454 DOI: 10.3390/bios11120507] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 12/14/2022]
Abstract
Understanding the levels of glucose (G) and lactate (L) in blood can help us regulate various chronic health conditions such as obesity. In this paper, we introduced an enzyme-based electrochemical biosensor adopting glucose oxidase and lactate oxidase on two working screen-printed carbon electrodes (SPCEs) to sequentially determine glucose and lactate concentrations in a single drop (~30 µL) of whole blood. We developed a diet-induced obesity (DIO) mouse model for 28 weeks and monitored the changes in blood glucose and lactate levels. A linear calibration curve for glucose and lactate concentrations in ranges from 0.5 to 35 mM and 0.5 to 25 mM was obtained with R-values of 0.99 and 0.97, respectively. A drastic increase in blood glucose and a small but significant increase in blood lactate were seen only in prolonged obese cases. The ratio of lactate concentration to glucose concentration (L/G) was calculated as the mouse’s gained weight. The results demonstrated that an L/G value of 0.59 could be used as a criterion to differentiate between normal and obesity conditions. With L/G and weight gain, we constructed a diagnostic plot that could categorize normal and obese health conditions into four different zones. The proposed dual electrode biosensor for glucose and lactate in mouse whole blood showed good stability, selectivity, sensitivity, and efficiency. Thus, we believe that this dual electrode biosensor and the diagnostic plot could be used as a sensitive analytical tool for diagnosing glucose and lactate biomarkers in clinics and for monitoring obesity.
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Mariano F, Biancone L. Metformin, chronic nephropathy and lactic acidosis: a multi-faceted issue for the nephrologist. J Nephrol 2020; 34:1127-1135. [PMID: 33373028 PMCID: PMC8357762 DOI: 10.1007/s40620-020-00941-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/30/2020] [Indexed: 12/15/2022]
Abstract
Metformin is currently considered a first-line therapy in type 2 diabetic patients. After issuing warnings for decades about the risks of lactic acidosis in patients with chronic nephropathy, metformin is now being re-evaluated. The most recent evidence from the literature has demonstrated both a low, acceptable risk of lactic acidosis and a series of favorable effects, which go beyond its hypoglycemic activity. Patients treated with metformin show a significant mortality reduction and lower progression towards end-stage renal disease in comparison with those treated with other hypoglycemic drugs. Concerning lactic acidosis, in the last few years it has been shown how lactic acidosis almost always developed when patients kept taking the drug in the face of a concomitant disease or situation such as sepsis, fever, diarrhea, vomiting, which reduced metformin renal clearance. Actually, clearance of metformin is mainly renal, both by glomerular filtration and tubular secretion (apparent clearance 933–1317 ml/min, half-life < 3 h). As regards treatment, in cases of lactic acidosis complicated by acute kidney injury, continuous renal replacement therapy (CRRT) plays a crucial role. Besides the elimination of metformin, CRRT improves survival by correcting acidosis, electrolyte alterations, and maintaining fluid balance. Lactic acidosis almost always develops because of preventable drug accumulation. Therefore, prevention is a key factor. Patients should be aware that discontinuation for a limited time does not affect their health, even when it may be inappropriate, but it may avoid a serious, potentially fatal adverse event.
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Affiliation(s)
- Filippo Mariano
- Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Luigi Biancone
- Department of Medical Sciences, University of Turin, Turin, Italy
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van Berlo-van de Laar IRF, Gedik A, van 't Riet E, de Meijer A, Taxis K, Jansman FGA. Identifying patients with metformin associated lactic acidosis in the emergency department. Int J Clin Pharm 2020; 42:1286-1292. [PMID: 32960426 PMCID: PMC7522070 DOI: 10.1007/s11096-020-01069-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/27/2020] [Indexed: 12/29/2022]
Abstract
Background Metformin associated lactic acidosis (MALA) is a serious adverse event with a high mortality rate of 30-50%. Early recognition of MALA and timely starting treatment may reduce its morbidity and mortality. Objective The aim of this study was to explore clinical parameters to identify patients with MALA in patients with suspected sepsis induced lactic acidosis in the emergency department ED. Setting A retrospective single centre study was conducted at the Deventer Teaching Hospital in the Netherlands. Method Patients with lactate concentration > 4.0 mmol/l admitted at the ED between 2010 and 2017 with suspected sepsis or confirmed MALA and referred to the Intensive Care Unit were included. Baseline characteristics (pH, lactate, creatinine and CRP) of MALA patients were compared with patients with suspected sepsis induced lactic acidosis. Creatinine and lactate concentration were selected as potential relevant parameters. Main outcome measure Sensitivity and specificity of the highest tertiles of the creatinine and the lactate concentrations separately, in combination, and both combined with metformin use, were calculated. Results Thirteen MALA and 90 suspected sepsis induced lactic acidosis patients were included. Lactate (14.7 vs 5.9 mmol/l, p < 0.01) and creatinine concentration (642 vs 174 μmol/l, p < 0.01) were significantly higher in the MALA group and arterial pH (7.04 vs 7.38, p < 0.01) and CRP (90 vs 185 mg/l, p < 0.01) were significantly lower. The combined parameters lactate ≥ 8.4 mmol/l, creatinine ≥ 256 μmol/l had a sensitivity of 85% and a specificity of 95% for identifying MALA in suspected sepsis induced lactic acidosis patients in the ED. When combined with metformin use the specificity increased to 99%. Conclusion When managing lactic acidosis in the ED the diagnosis MALA should be considered in patients with a creatinine concentration ≥ 256 μmol/l and lactate concentration ≥ 8.4 mmol/l.
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Affiliation(s)
- I R F van Berlo-van de Laar
- Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, 7400 GC, P.O. Box 5001, 7416 SE, Deventer, The Netherlands.
| | - A Gedik
- Department of Internal Medicine, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - E van 't Riet
- Department of Research and Innovation, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - A de Meijer
- Department of Intensive Care, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - K Taxis
- Unit of PharmacoTherapy, -Epidemiology &-Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - F G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, 7400 GC, P.O. Box 5001, 7416 SE, Deventer, The Netherlands
- Unit of PharmacoTherapy, -Epidemiology &-Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
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Matyukhin I, Patschan S, Ritter O, Patschan D. Etiology and Management of Acute Metabolic Acidosis: An Update. Kidney Blood Press Res 2020; 45:523-531. [PMID: 32663831 DOI: 10.1159/000507813] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/08/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The etiology of acute metabolic acidosis (aMA) is heterogeneous, and the consequences are potentially life-threatening. The aim of this article was to summarize the causes and management of aMA from a clinician's perspective. SUMMARY We performed a systematic search on PubMed, applying the following search terms: "acute metabolic acidosis," "lactic acidosis," "metformin" AND "acidosis," "unbalanced solutions" AND "acidosis," "bicarbonate" AND "acidosis" AND "outcome," "acute metabolic acidosis" AND "management," and "acute metabolic acidosis" AND "renal replacement therapy (RRT)/dialysis." The literature search did not consider diabetic ketoacidosis at all. Lactic acidosis evolves from various conditions, either with or without systemic hypoxia. The incidence of metformin-associated aMA is actually quite low. Unbalanced electrolyte preparations can induce hyperchloremic aMA. The latter potentially worsens kidney-related outcome parameters. Nevertheless, prospective and controlled data are missing at the moment. Recently, bicarbonate has been shown to improve clinically relevant endpoints in the critically ill, even if higher pH values (>7.3) are targeted. New therapeutics for aMA control are under development, since bicarbonate treatment can induce serious side effects. Key Messages: aMA is a frequent and potentially life-threatening complication of various conditions. Lactic acidosis might occur even in the absence of systemic hypoxia. The incidence of metformin-associated aMA is comparably low. Unbalanced electrolyte solutions induce hyperchloremic aMA, which most likely worsens the renal prognosis of critically ill patients. Bicarbonate, although potentially deleterious due to increased carbon dioxide production with subsequent intracellular acidosis, improves kidney-related endpoints in the critically ill.
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Affiliation(s)
- Igor Matyukhin
- Zentrum Innere Medizin 1, Kardiologie, Angiologie, Nephrologie, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, Brandenburg an der Havel, Germany
| | - Susann Patschan
- Zentrum Innere Medizin 1, Kardiologie, Angiologie, Nephrologie, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, Brandenburg an der Havel, Germany
| | - Oliver Ritter
- Zentrum Innere Medizin 1, Kardiologie, Angiologie, Nephrologie, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, Brandenburg an der Havel, Germany
| | - Daniel Patschan
- Zentrum Innere Medizin 1, Kardiologie, Angiologie, Nephrologie, Klinikum Brandenburg, Medizinische Hochschule Brandenburg, Brandenburg an der Havel, Germany,
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van Berlo-van de Laar IRF, Vermeij CG, van den Elsen-Hutten M, de Meijer A, Taxis K, Jansman FGA. Extracorporeal treatment of metforminassociated lactic acidosis in clinical practice: a retrospective cohort study. Eur J Clin Pharmacol 2020; 76:815-820. [PMID: 32170333 PMCID: PMC7239820 DOI: 10.1007/s00228-020-02857-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/05/2020] [Indexed: 11/26/2022]
Abstract
Purpose To assess whether extracorporeal treatment (ECTR) improves outcome of patients with metformin-associated lactic acidosis (MALA) and to evaluate the clinical applicability of the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP) criteria for starting ECTR in metformin poisoning. Methods Patients with metformin serum concentrations above 2 mg/l who were admitted in the Deventer Teaching Hospital between January 2000 and July 2019 and complied with the definition of MALA (pH < 7.35 and lactate concentration > 5 mmol/l) were included. Mortality and clinical parameters of patients treated with ECTR or not were compared. In addition, treatment of MALA in clinical practice was verified against the criteria of EXTRIP. Results Forty-two patients were included. Lactate (13.8 versus 10.5 mmol/l, p = 0.01), creatinine (575 versus 254 umol/l, p < 0.01)), metformin (29.4 versus 8.6 mg/l, p < 0.01) concentrations, and vasopressor requirement (72% versus 23%, p < 0.01) were significantly higher in the ECTR-group. Blood pH (7.05 versus 7.19, p = 0.03) and bicarbonate (6 versus 11 mmol/l, p < 0.01) were significantly lower. Mortality, length of hospital stay, and mechanical ventilation requirement were not statistically different. In 83% of patients, treatment of MALA was in accordance with the EXTRIP criteria. Conclusions Although there was no statistical benefit in mortality shown from ECTR, ECTR might be lifesaving in MALA, considering the ECTR-group was significantly sicker than the non-ECTR-group. The majority of patients were treated in line with the EXTRIP criteria. Severity of lactic acidosis and renal impairment were the main indications for initiating ECTR. Electronic supplementary material The online version of this article (10.1007/s00228-020-02857-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Inge R F van Berlo-van de Laar
- Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, P.O. Box 5001, 7400 GC, Deventer, The Netherlands.
| | - Cornelis G Vermeij
- Department of Internal Medicine, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - Marjo van den Elsen-Hutten
- Department of Research and Innovation, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - Arthur de Meijer
- Department of Intensive Care, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, -Epidemiology &-Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Frank G A Jansman
- Department of Clinical Pharmacy, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, P.O. Box 5001, 7400 GC, Deventer, The Netherlands
- Unit of PharmacoTherapy, -Epidemiology &-Economics, Groningen Research Institute of Pharmacy (GRIP), University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
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Waldauf P, Jiroutkova K, Duska F. Using pCO 2 Gap in the Differential Diagnosis of Hyperlactatemia Outside the Context of Sepsis: A Physiological Review and Case Series. Crit Care Res Pract 2019; 2019:5364503. [PMID: 31885914 PMCID: PMC6914888 DOI: 10.1155/2019/5364503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 10/17/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION There is an inverse relationship between cardiac output and the central venous-arterial difference of partial pressures of carbon dioxide (pCO2 gap), and pCO2 gap has been used to guide early resuscitation of septic shock. It can be hypothesized that pCO2 gap can be used outside the context of sepsis to distinguish type A and type B lactic acidosis and thereby avoid unnecessary fluid resuscitation in patients with high lactate, but without organ hypoperfusion. METHODS We performed a structured review of the literature enlightening the physiological background. Next, we retrospectively selected a series of case reports of nonseptic critically ill patients with elevated lactate, in whom both arterial and central venous blood gases were simultaneously measured and the diagnosis of either type A or type B hyperlactataemia was conclusively known. In these cases, we calculated venous-arterial CO2 and O2 content differences and pCO2 gap. RESULTS Based on available physiological data, pCO2 can be considered as an acceptable surrogate of venous-arterial CO2 content difference, and it should better reflect cardiac output than central venous saturation or indices based on venous-arterial O2 content difference. In our case report of nonseptic patients, we observed that if global hypoperfusion was present (i.e., in type A lactic acidosis), pCO2 gap was elevated (>1 kPa), whilst in the absence of it (i.e., in type B lactic acidosis), pCO2 gap was low (<0.5 kPa). CONCLUSION Physiological rationale and a small case series are consistent with the hypothesis that low pCO2 gap in nonseptic critically ill is suggestive of the absence of tissue hypoperfusion, mandating the search for the cause of type B lactic acidosis rather than administration of fluids or other drugs aimed at increasing cardiac output.
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Affiliation(s)
- Petr Waldauf
- Department of Anaesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czech Republic
| | - Katerina Jiroutkova
- Department of Anaesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czech Republic
- Oxylab: Lab of Mitochondrial Physiology, The Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Frantisek Duska
- Department of Anaesthesia and Intensive Care Medicine, The Third Faculty of Medicine, Charles University and FNKV University Hospital, Prague, Czech Republic
- Oxylab: Lab of Mitochondrial Physiology, The Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Abstract
PURPOSE OF REVIEW The number of bariatric surgeries for patients with type 1 or type 2 diabetes continues to grow. Clinicians are challenged to choose therapies that reach glycemic targets without inducing adverse effects in post-bariatric patients without published guidelines. This review evaluates data supporting the best strategies for diabetes management in patients undergoing bariatric surgery. RECENT FINDINGS Though few clinical trials have evaluated the safety and effectiveness of different glucose-lowering therapies following bariatric surgery, remission of diabetes or reduced medications is an established benefit of bariatric surgery. Adverse events including diabetic ketoacidosis in post-bariatric patients on sodium-glucose co-transporter 2 (SGLT2) inhibitors or inadequate insulin have been reported in patient's with both type 1 and type 2 diabetes. Metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, SGLT2 inhibitors, insulin, and sulfonylureas have been used successfully in the perioperative period for other surgeries and guidelines recommend adjusting the doses of these medications especially in the perioperative period. Clinicians should favor weight-neutral or weight-loss promoting therapies in post-bariatric surgery patients such as medical nutrition therapy, metformin, GLP-1 agonists, SGLT2 inhibitors, and DPP-4 inhibitors.
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Affiliation(s)
- Christopher M Mulla
- Division of Endocrinology, Landstuhl Regional Medical Center, US Army, Landstuhl, Germany.
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA.
| | - Harris M Baloch
- Division of Endocrinology, Landstuhl Regional Medical Center, US Army, Landstuhl, Germany
| | - Samar Hafida
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
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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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Nephrology Consultation for Severe SGLT2 Inhibitor-Induced Ketoacidosis in Type 2 Diabetes: Case Report. ACTA ACUST UNITED AC 2019; 55:medicina55080462. [PMID: 31405158 PMCID: PMC6723212 DOI: 10.3390/medicina55080462] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/06/2019] [Accepted: 08/08/2019] [Indexed: 12/15/2022]
Abstract
Euglycemic diabetic ketoacidosis (euDKA) related to sodium-glucose cotransporter 2 inhibitor (SGLT2-I), despite being reported as consistent, though infrequent, adverse effect in all trials on SGLT2-I in type 2 diabetes mellitus (T2D), still remains poorly known in the real world. On the other hand, the use of this new class of antihyperglycemic agents is expected to increase based on the recent solid evidence of remarkable cardiorenal protection. Therefore, improving awareness on risk factors, diagnosis, and treatment of euDKA is essential to allow correct implementation of SGLT2-I in clinical practice. We here report a T2D patient admitted to the emergency department and then transferred to the nephrology-dialysis unit because of severe euglycemic diabetic ketoacidosis (euDKA) related to sodium-glucose cotransporter 2 inhibitor (SGLT2-I). In our patient, a concurrent acute kidney injury at presentation, initially attributed to excessive use of nonsteroid anti-inflammatory agents, and the absence of severe hyperglycemia led to delayed diagnosis and proper therapy. The detailed description of decision-making process for diagnosis and therapy, and the analysis of precipitating factors as well, discloses the helpful contribution of nephrologist to optimize prevention and management of euDKA.
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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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Boada Fernández del Campo C, Rodríguez Jimenez C, García Saiz M, Aldea Perona A, Sanz Álvarez E, Fernández Quintana E, García Sanchez-Colomer M, Huidobro Amaro S, Arbesú Cruz A, Jimenez Sosa A. Metformin-associated hyperlactacidaemia acidosis: Diagnosis rate in standard clinical practice and its relationship with renal failure. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Boada Fernández del Campo C, Rodríguez Jimenez C, García Saiz M, Aldea Perona A, Sanz Álvarez E, Fernández Quintana E, García Sanchez-Colomer M, Huidobro Amaro S, Arbesú Cruz A, Jimenez Sosa A. Acidosis con hiperlactacidemia por metformina: frecuencia de su diagnóstico en la práctica clínica habitual y relación con la insuficiencia renal. Rev Clin Esp 2019; 219:236-242. [DOI: 10.1016/j.rce.2018.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 11/26/2022]
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Greco P, Regolisti G, Maggiore U, Ferioli E, Fani F, Locatelli C, Parenti E, Maccari C, Gandolfini I, Fiaccadori E. Sustained low-efficiency dialysis for metformin-associated lactic acidosis in patients with acute kidney injury. J Nephrol 2018; 32:297-306. [PMID: 30523561 DOI: 10.1007/s40620-018-00562-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/14/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND The choice of the specific modality and treatment duration of renal replacement therapy (RRT) to adopt in metformin-associated lactic acidosis (MALA) is still debated. We aimed to verify if sustained low-efficiency dialysis (SLED) is a rational choice in patients with MALA and acute kidney injury (AKI). METHODS We collected serial serum metformin measurements, clinical parameters, and outcome data in ten consecutive patients (mean age 77 years [range 58-88], 5 males) admitted to our renal intensive care unit for suspected MALA associated with AKI and hemodynamic instability. Patients underwent a 16-h SLED session performed with either conventional dialysis machines or machines for continuous RRT (CRRT). A 2-compartment open-infusion pharmacokinetic model with first-order elimination was fitted to each subject's serum concentration-time data to model post-SLED rebound and predict the need for further treatments. RESULTS Two patients died within 24 h after SLED start. Three patients needed one further dialysis session. Surviving patients (n = 8) were dialysis-free at discharge. Metformin levels were in the toxic range at baseline (median [range] 32.5 mg/l [13.6-75.6]) and decreased rapidly by the end of SLED (8.1 mg/l [4.5-15.8], p < 0.001 vs. baseline), without differences according to the dialysis machine used (p = 0.84). We observed a slight 4-h post-SLED rebound (9.7 mg/l [3.5-22.0]), which could be predicted by our pharmacokinetic model. Accordingly, we predicted that the majority of patients would need one additional dialysis session performed the following day to restore safe metformin levels. CONCLUSIONS A 16-h SLED session, performed with either conventional dialysis machines or CRRT machines, allows effective metformin removal in patients with MALA and AKI. However, due to possible post-SLED rebound in serum metformin levels, one additional dialysis treatment is required the following day in the majority of patients.
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Affiliation(s)
- Paolo Greco
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuseppe Regolisti
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Umberto Maggiore
- Renal Transplant Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elena Ferioli
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Filippo Fani
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Carlo Locatelli
- Poison Control Centre and National Toxicology Information Centre, Toxicology Unit, Istituti Clinici Scientifici Maugeri Spa-SB, IRCCS Pavia Hospital and University of Pavia, Pavia, Italy
| | - Elisabetta Parenti
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Caterina Maccari
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ilaria Gandolfini
- Renal Transplant Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Enrico Fiaccadori
- Acute and Chronic Renal Failure Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Gharia B, Seegobin K, Mahida H, Shaikh M, Matthews Hew T, Pham D. Fatal Type B Lactic Acidosis Associated With Metastatic Colorectal Cancer: A Case Report With Review of Literature, Pathogenesis, and Treatment. J Investig Med High Impact Case Rep 2018; 6:2324709618788101. [PMID: 30038911 PMCID: PMC6053866 DOI: 10.1177/2324709618788101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/30/2018] [Accepted: 06/12/2018] [Indexed: 12/11/2022] Open
Abstract
Type B lactic acidosis associated with malignancy is a life-threatening complication and mostly seen in hematological malignancies but can also be seen in solid tumors. We report a rare case of a 64-year-old female diagnosed with metastatic adenocarcinoma of the colon with liver metastasis associated with severe type B lactic acidosis. We discuss pathophysiology, previously reported cases, and their outcomes. The most widely used therapies are bicarbonate infusion, thiamine supplementation, chemotherapy, and supportive care but is associated with poor outcomes, and no standard treatment recommendations are available. Early chemotherapy administration remains the only intervention that has shown some survival benefit. Physicians should be aware and proactive for early diagnosis and management of this condition with further research needed to guide optimal therapy.
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Affiliation(s)
| | | | - Hetavi Mahida
- Jersey Shore University Medical Center, Neptune City, NJ, USA
| | | | | | - Dat Pham
- University of Florida, Jacksonville, FL, USA
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McCabe DJ, Baker S, Stellpflug SJ. Hemodialysis in metformin-associated lactic acidosis due to acute overdose in a metformin-naïve patient. Am J Emerg Med 2018; 36:1721.e1-1721.e2. [PMID: 29861374 DOI: 10.1016/j.ajem.2018.05.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 05/29/2018] [Indexed: 12/20/2022] Open
Abstract
Metformin is a common and generally well-tolerated medication in the treatment of diabetes but rarely has been implicated as the cause for metformin-associated lactate acidosis. This is usually caused by decreased elimination from renal dysfunction but is rarely described after an acute ingestion. We present a case of an acute intentional overdose of metformin in a metformin-naïve patient without renal dysfunction. The patient gradually developed altered mental status, tachypnea, hypotension, hyperglycemia, hypoglycemia, hypothermia, and vasoplegic shock unresponsive to vasopressor support. Despite attempts at alkalinization, the patient developed a lactic acidosis with a pH of 6.9 and lactate of 33 mmol/L. Hemodialysis was performed with rapid improvement of clinical status. This case provides a clinical context in the acute setting and illustrates the rare need for extracorporeal support in this setting, which may be lifesaving.
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Affiliation(s)
- Daniel J McCabe
- Department of Emergency Medicine, Regions Hospital, St Paul, MN, United States; Minnesota Poison Control Center, Minneapolis, MN, United States.
| | - Sarah Baker
- Department of Emergency Medicine, Regions Hospital, St Paul, MN, United States
| | - Samuel J Stellpflug
- Department of Emergency Medicine, Regions Hospital, St Paul, MN, United States; Minnesota Poison Control Center, Minneapolis, MN, United States
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Filippatos T, Tzavella E, Rizos C, Elisaf M, Liamis G. Acid-base and electrolyte disorders associated with the use of antidiabetic drugs. Expert Opin Drug Saf 2017; 16:1121-1132. [DOI: 10.1080/14740338.2017.1361400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Theodosios Filippatos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Eleftheria Tzavella
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Christos Rizos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Moses Elisaf
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Nakamura A, Suzuki K, Imai H, Katayama N. Metformin-associated lactic acidosis treated with continuous renal replacement therapy. BMJ Case Rep 2017; 2017:bcr-2016-218318. [PMID: 28188168 DOI: 10.1136/bcr-2016-218318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Metformin-associated lactic acidosis (MALA) is a rare but life-threatening complication. We report a case of MALA in a man aged 71 years who was treated with continuous renal replacement therapy (CRRT). The patient was brought to the hospital for prolonged and gradual worsening gastrointestinal symptoms. Although he received intravenous treatment, he developed catecholamine-resistant shock, and blood gas analysis revealed lactic acidosis. Bicarbonate and antibiotics for possible sepsis were initiated, but with no clear benefit. Owing to haemodynamic instability with metabolic acidosis, urgent CRRT was given: it was immediately effective in reducing lactate levels; pH values completely normalised within 18 hours, and he was stabilised. MALA sometimes presents with non-specific symptoms, and is important to consider when treating unexplainable metabolic acidosis. In severe cases, CRRT has potential merit, particularly in haemodynamically unstable patients. It is important to be familiar with MALA as a medical emergency, even for emergency physicians.
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Affiliation(s)
- Akihide Nakamura
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan.,Mie University Hospital, The Emergency and Critical Care Center, Tsu, Japan
| | - Kei Suzuki
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan.,Mie University Hospital, The Emergency and Critical Care Center, Tsu, Japan
| | - Hiroshi Imai
- Mie University Hospital, The Emergency and Critical Care Center, Tsu, Japan
| | - Naoyuki Katayama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
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Brönnimann A, Rudofsky G, Paganoni R, Studhalter M. [Not Available]. PRAXIS 2017; 106:1397-1400. [PMID: 29231088 DOI: 10.1024/1661-8157/a002849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Wir berichten über einen 72-jährigen Patienten mit progredienten Bauchschmerzen, Nausea und Dyspnoe seit Tagen bei vorbekannter Leberzirrhose und Diabetes mellitus. Trotz begonnener antibiotische Therapie bei spontan bakterieller Peritonitis verschlechterte sich der Zustand des Patienten weiter, sodass er in schwerstem Schockzustand auf die Intensivstation verlegt wurde. Bei schwerer Laktatazidose, Schock sowie Einnahme von Metformin wurde eine Metformin-assoziierte Laktatazidose diagnostiziert. Der Säure-Basen-Status liess sich unter kontinuierlicher Hämodiafiltration komplett korrigieren. Der Patient starb aber an einem Leberversagen bei vorbestehender Leberzirrhose.
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Affiliation(s)
- Alain Brönnimann
- 1 Departement Perioperative Medizin, Intensivmedizin Kantonsspital Olten
| | | | - Reto Paganoni
- 1 Departement Perioperative Medizin, Intensivmedizin Kantonsspital Olten
| | - Michael Studhalter
- 1 Departement Perioperative Medizin, Intensivmedizin Kantonsspital Olten
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Abstract
AIMS The principal objective of this study was to retrospectively review a series of cases of lactic acidosis (LA) in patients with type 2 diabetes mellitus (T2DM) and examine the relationship with the use of metformin. More generally, the study enabled an investigation of the profiles of patients diagnosed with LA and clinical variables associated with in-hospital mortality. METHODS All patients admitted to the Royal Hobart Hospital in Tasmania with LA (lactate >5.0 mmol/L and pH <7.35) over a 4-year period were included. Data extracted included patient demographics, medical history, medications, acute and chronic conditions associated with LA, and relevant pathology results. Multivariate logistic regression analysis was used to identify predictors for in-hospital mortality in patients with LA. RESULTS A total of 139 patients with LA were included in this study. Of these, 23 patients had T2DM and 11 patients were taking metformin. All metformin-treated patients had at least 1 additional medical condition (either chronic or acute) associated with an increased risk for LA. More than half (n = 72, 51.8%) of the patients with LA died during hospitalization. Multivariate logistic regression revealed older age and lower pH as the significant independent predictors (P < 0.05) for in-hospital mortality. CONCLUSION LA was associated with high in-hospital mortality, with older age and lower pH as the significant risk factors for mortality. In patients with LA, approximately half of the patients with T2DM were receiving metformin. All the patients treated with metformin had other medical conditions that were risk factors for developing LA. The role of LA in patients treated with metformin is seemingly overemphasized.
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Affiliation(s)
- Weiyi Huang
- PhD Candidate, Unit for Medication Outcomes Research and Education, Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Australia
| | - Ronald L. Castelino
- Senior Lecturer in Pharmacology & Clinical Pharmacy, Sydney Nursing School, University of Sydney, Australia; Adjunct senior lecturer, Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Australia
| | - Gregory M. Peterson
- Deputy Dean (Research), Faculty of Health, University of Tasmania, Australia; Co-Director, Health Services Innovation (Tasmania), School of Medicine, Faculty of Health, University of Tasmania, Australia
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