Identifying patients with metformin associated lactic acidosis in the emergency department

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.

Utility of support vector machine and decision tree to identify the prognosis of metformin poisoning in the United States: analysis of National Poisoning Data System

“…MALA has been reported to occur at up to 138 per 100,000 patients per year [ 25 ]. It should be noted that early diagnosis of MALA is critical, and it should be suspected in patients with creatinine concentrations of 256 mol/l or higher and lactate concentrations of 8.4 mmol/l or higher [ 26 ]. MALA pathogenesis is attributed to a mitochondria blockage of the complex 1 respiratory chain [ 27 ].…”

Metformin toxicity in the intensive care unit: A case series and review of the literature

“…[ 20 23 ] Diagnostically, the combined presence of acute renal failure, pH ≤7.35, lactate ≥8.4 mmol/L, and known use of metformin is sensitive and specific for MALA. [ 41 ] Once identified, the treatment is supportive with the use of IV fluids, vasopressors, and dextrose drips. [ 35 39 ] Most important is the immediate implementation of dialysis.…”

“…Several studies have compared CRRT, conventional HD, and SLED, all of which have shown benefit in the treatment of MALA. [ 36 37 38 39 41 ] ECMO may provide the necessary hemodynamic support if dialysis and supportive care are insufficient. [ 25 ]…”

Risk of Lactic Acidosis in Hospitalized Diabetic Patients Prescribed Biguanides in Japan: A Retrospective Total-Population Cohort Study

“…In addition, the actual diagnosis of LA is difficult without information that metformin was used. As reported by van Berlo-van de Laar IRF et al, the sensitivity of identifying metformin-associated LA in patients with sepsis-induced lactic acidosis suspected is 85% when even using the recommended parameters (lactate ≥ 8.4 mmol/L, creatinine ≥ 256 μmol/L), and a specificity is 95% [ 41 ]. Under this circumstance, underreporting cases should be considered.…”