Suicide commitment with metformin: our experience with five cases

Metformin toxicity: A meta-summary of case reports

BACKGROUND

Metformin is arguably the most commonly prescribed oral hypoglycemic agent for the management of diabetes. Due to the lack of randomized control trials, most of the data pertaining to the clinical course, therapeutic interventions and outcomes of patients with metformin induced toxicity has come from case reports or series.

AIM

To analyse the symptomology, clinical interventions and outcomes of patients presenting with severe metformin toxicity by reviewing the published case reports and series.

METHODS

We performed a systematic search from PubMed, Science Direct, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Google Scholar databases using the terms “metformin” AND “toxicity” OR “overdose” OR “lactic acidosis” OR “hyperlactatemia”. The inclusion criteria were: (1) Case reports or case series with individual patient details; and (2) Reported toxicity or overdose of metformin in adults, published in the English language. Data regarding baseline demographics, clinical presentation, therapeutic interventions, intensive care unit course and overall outcome were collected.

RESULTS

Two hundred forty-two individual cases were analysed, from 158 case reports and 26 case series, with a cumulative mortality of 19.8%. 214 (88.4%) patients were diabetics on metformin. 57 (23.6%) had acute ingestion, but a great majority (76.4%) were on metformin in therapeutic doses when they developed toxicity. Metformin associated lactic acidosis (MALA) was the most commonly reported adverse effect present in 224 (92.6%) patients. Most of the patients presented with gastrointestinal and neurological symptoms and a significant number of patients had severe metabolic acidosis and hyperlactatemia. The organ support used was renal replacement therapy (RRT) (68.6%), vaso-pressors (58.7%) and invasive mechanical ventilation (52.9%). A majority of patients (68.6%) received RRT for toxin removal, renal dysfunction and correction of MALA. Patients with lowest pH and highest serum lactate and metformin levels also had favourable outcomes with use of RRT.

CONCLUSION

Most of the reported cases were on therapeutic doses of metformin but developed toxicity after an acute deterioration in renal functions. These patients may develop severe lactic acidosis, leading to significant morbidity and need for organ support. Despite severe MALA and the need for multiple organ support, they may have good outcomes, especially when RRT is used. The dose of metformin, serum pH, lactate and metformin levels may indicate the severity of toxicity and the need for aggressive therapeutic measures but may not necessarily indicate poor outcomes.

Risk of Depression and Suicide in Diabetic Patients

Although mental disorders in diabetics are more prevalent than in the general population, an increased prevalence of depression, frequently leading to suicide, has been reported in individuals with diabetes mellitus. Therefore, the purpose of this review is to assess the risk of depression and suicide in diabetic patients. The prevalence of depression and suicide is high among diabetic individuals. Risk factors including history of depression, presence of comorbidity, younger age, lower education, low social support, presence of diabetic complications, poor glycemic control, and physical impairment, all increase the risk of depression among diabetics. On the other hand, female sex, the intensity of childhood trauma, a history of alcohol misuse, depression, lower level of education, comorbidities, higher blood glucose levels, and previous history of suicide, all increase the risk of suicide among diabetics. Additionally, a bidirectional relationship exists between depression and diabetes. For example, depression can cause diabetes due to the disease's psychological and psychosocial impact, microvascular brain lesions, higher glutamate levels, poor glycemic control, and medication adherence. On the other hand, diabetic patients develop depression due to the stress associated with disease management. This paper concluded that depression and suicide are both prevalent conditions among diabetic patients. The higher risk of depression and suicidality in diabetic patients emphasizes the critical need of integrating depression screening and treatment into primary healthcare settings to avoid fatal conditions in the future. However, more research is required in this area.

Clinical Characteristics of Diabetes Mellitus and Suicide Risk

BACKGROUND

Diabetes mellitus (DM) is a chronic illness with impaired health-related quality of life and a high risk of psychiatric disorders. We carried out a systematic review analyzing the relationship between DM and suicide by providing a qualitative data synthesis of the studies.

METHODS

We conducted, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of the literature in PubMed, Scopus, ISI Web of Science, PsycINFO, Google Scholar, and ScienceDirect. Search terms were "suicid*" combined with the Boolean "AND" operator with "diabetes."

RESULTS

The initial search identified 568 citations. A total of 17 research reports met the predefined inclusion criteria and were analyzed. DM was found to be significantly associated with a marked increase in suicidal behaviors and suicidal ideation (SI), especially in patients with depressive symptoms. Insulin therapy, DM of long duration, and unsatisfactory glycemic control were identified as risk factors for SI in Type 1 (T1DM) and Type 2 (T2DM).

CONCLUSION

Health-care professionals need to be aware of the higher suicidal risk in patient subgroups based on the clinical characteristics of DM; thus, patients with these characteristics warrant special attention. In this regard, clinical management should include efforts to manage emotional distress in DM care.

Factors affecting the decision to hospitalise children admitted to the emergency department due to non-fatal suicide attempts by pills

Objective:

Suicide attempts (SAs) in the paediatric age group represent an important cause of morbidity and mortality. Our aim was to examine the factors affecting the decision to hospitalize children with a diagnosis of non-fatal SA by pills.

Methods:

Children <18 years of age admitted with SA by pills during 2014 were evaluated retrospectively. Patients were divided into two groups: Group-I comprised hospitalised patients and Group-II included those who were discharged from the PED. These two groups were compared in terms of clinical and demographic characteristics recorded upon PED admission.

Results:

A total of 196 patients were included in the study. The number of pills taken for self-poisoning in Group-I (median: 20 pills) was higher than that in Group-II (median: 12 pills) (p < 0.001), and the rate of pathological findings during the first paediatric psychiatric consultation was higher in Group-I (91.1%) than in the Group-II (54.8%) (p < 0.001).

Conclusion:

Factors affecting the disposition decision in cases of children who performed non-fatal SA via pills included the amount of medication taken for the suicide attempt and the presence of psychiatric disorders, as determined by a paediatric psychiatrist during the acute phase.

Repositioning metformin in cancer: genetics, drug targets, and new ways of delivery

After sitting many years on the shelves of drug stores as a harmless antidiabetic drug, metformin comes back in the spotlight of the scientific community as a surprisingly effective antineoplastic drug. Metformin targets multiple pathways that play pivotal roles in cancer progression, impacting various cellular processes, such as proliferation, cell death, metabolism, and even the cancer stemness features. The biomolecular characteristics of tumors, such as appropriate expression of organic cation transporters or genetic alterations including p53, K-ras, LKB1, and PI3K may impact metformin's anticancer efficiency. This could indicate a need for tumor genetic profiling in order to identify patients most likely to benefit from metformin treatment. Considering that the majority of experimental models suggest that higher, supra-clinical doses of metformin should be used in order to obtain an antineoplastic effect, new ways of drug delivery could be developed, such as metformin-loaded nanoparticles or incorporation of metformin into microparticles used in transarterial chemoembolization, with the aim of obtaining higher intratumoral drug concentrations and a targeted therapy which will ultimately maximize metformin's efficacy.

Colchicine intoxication: a report of two suicide cases

Colchicine, an old and well-known drug, is an alkaloid extracted from Colchicum autumnale and related species. Colchicine inhibits the deposition of uric acid crystals and is an inhibitor of mitosis. Nausea, vomiting, abdominal pain, and diarrhea, with a massive loss of fluid and electrolytes are the first clinical symptoms of colchicine poisoning. Stomach lavage and rapid gastric decontamination with activated charcoal are crucial. An acute dose of about 0.8 mg/kg of colchicine is presumed to be fatal. We report the clinical outcomes of two different cases of colchicine intoxication for attempted suicide. The dose required for morbidity or mortality varies significantly. The dose of 1 mg/kg in the first case was directly related with mortality, while the dose of 0.2 mg/kg in the second was related with survival. The other difference between the patients was the time of arrival to hospital after ingestion. This period was 4 hours for case 1 and only 1, hour for case 2. The initiation of treatment later than 2 hours after ingestion of colchicine may significantly impair treatment because the absorption time for colchicine after oral administration is about 30-120 minutes. The rising lactate level and high anion gap metabolic acidosis in our patient (case 1) were attributed to lactic acidosis, so hemodialysis was performed, and the duration of hemodialysis was prolonged. Lactic acidosis in the first case was one of the reasons for mortality. The most important parameters which define the chance of survival are the dose of ingested drugs and the arrival time to hospital after ingestion. The patients must be monitored closely for lactic acidosis and the decision to start hemodialysis must be made promptly for patients who develop lactic acidosis.