Incidence and risk factors for hyperlactatemia in ED patients with acute metformin overdose

Taub, Emily S.; Hoffman, Robert S.; Manini, Alex F.

doi:10.1016/j.ajem.2019.03.033

Cited by 6 publications

(6 citation statements)

References 26 publications

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“…In fact, the causes of death were ethylene glycol, salicylates, beta‐blockers, metformin overdose, and carbon monoxide inhalation, which could be associated to a low oxygen concentration in cells. Besides, these findings are consistent with other studies where the correlation between hyperlactatemia, early mortality, and certain toxics was reported 31‐33 …”

Section: Discussionsupporting

confidence: 93%

“…Besides, these findings are consistent with other studies where the correlation between hyperlactatemia, early mortality, and certain toxics was reported. [31][32][33] Patients within the respiratory group presented an already bad baseline situation, which means that they must continually correct their hypoxemic state, disrupting the buffer systems that balance tissue perfusion 34,35 and making the pLA changes. On the contrary, in neurological pathologies (eg a sudden attack or stroke), the effects are exclusively local as compared to the other pathologies where these effects are systemic; this could explain why the pLA levels did not presented a relevant alteration at the time of EMS assistance.…”

Section: Discussionmentioning

confidence: 99%

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Accuracy of prehospital point‐of‐care lactate in early in‐hospital mortality

Martin-Rodríguez

López-Izquierdo

Medina-Lozano

et al. 2020

Eur J Clin Investigation

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Background: Emergency medical services (EMS) routinely face complex scenarios where decisions should be taken with limited clinical information. The development of fast, reliable and easy to perform warning biomarkers could help in such decisionmaking processes. The present study aims at characterizing the validity of point-ofcare lactate (pLA) during prehospital tasks for predicting in-hospital mortality within two days after the EMS assistance. Materials and methods: Prospective, multicentric, ambulance-based and controlled observational study without intervention, including six advanced life support and five hospitals. The pLA levels were recorded during EMS assistance of adult patients. The validity of pLA to determine the in-hospital mortality was assessed by the area under the curve (AUC) of the receiver operating curve (ROC). Results: A total of 2997 patients were considered in the study, with a median of 69 years (IQR 54-81) and 41.4% of women. The median pLA value was 2.7 mmol/L (1.9-3.8) in survivors and 5.7 mmol/L (4.4-7.6) in nonsurvivors. The global discrimination level of pLA reached an AUC of 0.867, being 1.9 mmol/L and 4 mmol/L the cutoff point for low and high mortality. The discrimination value of pLA was not affected by sex, age or pathology. Conclusions: Our results highlight the clinical importance of prehospital pLA to determine the in-hospital risk of mortality. The incorporation of pLA into the EMS protocols could improve the early identification of risky patients, leading to a better care of such patients. K E Y W O R D S clinical clerkship, critical care, emergency medical services, lactate, point-of-care testing 2 of 10 | MARTÍN-RODRÍGUEZ ET Al.

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Accuracy of prehospital point‐of‐care lactate in early in‐hospital mortality

Martin-Rodríguez

López-Izquierdo

Medina-Lozano

et al. 2020

Eur J Clin Investigation

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“…e medication operates by promoting euglycemia and inhibiting gluconeogenesis in the liver, as well as increasing insulin sensitivity [1,2]. Despite its relative safety and efficacy, toxic ingestions of metformin have been reported in the literature with often high morbidity and mortality [2][3][4][5][6]. Metformin-associated lactic acidosis (MALA) has been coined as the reason for renal damage as well as multisystem organ failure often leading to death in such cases [2].…”

Section: Introductionmentioning

confidence: 99%

Profound Metabolic Acidosis due to Metformin Intoxication Requiring Dialysis

Hermez

Dudash-Mion

2021

Case Reports in Nephrology

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Metformin-associated lactic acidosis (MALA) is a rare but life-threatening condition with often high mortality rates. Despite this, metformin continues to be one of the most commonly prescribed antihyperglycemic agents in the market. We present a unique case of a 61-year-old female with severe acidosis of pH = 6.72 and lactic acid of 26 mmol/L who presented obtunded after ingestion of an unknown amount of metformin. She was subsequently intubated, became hypotensive, and was initiated on vasopressors. She was swiftly started on a combination of intermittent hemodialysis (IHD) and bicarbonate therapy 7 hours after admission followed by continuous renal replacement therapy (CRRT) as she became more hemodynamically unstable. The patient’s renal function improved, and she was discharged 7 days after admission with favorable sequelae. Dialysis is often reported in cases of severe MALA; however, it remains unclear how quickly dialysis should be initiated. This case aims to explore the benefits of quick initiation of extracorporeal measures in the forms of IHD and CRRT with concurrent bicarbonate supplementation. Furthermore, this case demonstrates the importance of clinical suspicion in metabolic acidosis in a patient on metformin therapy.

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“…Since the 1950s, metformin has been successfully used as a first-line pharmacotherapy for treating individuals with type II diabetes [1]. Although it is considered as a drug with a broad safety profile, metformin-associated lactic acidosis (MALA) is a widely documented adverse event [2,3]. MALA is a rare condition associated with poor prognoses and has an estimated mortality of between 25 and 50% [4].…”

Section: Introductionmentioning

confidence: 99%

The usefulness of measuring the anion gap in diagnosing metformin-associated lactic acidosis: a case series

et al. 2021

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Background Metformin-associated lactic acidosis (MALA) is a widely documented adverse event of metformin. Despite being considered one of the main causes of metabolic acidosis, the association between an anion gap and MALA diagnosis is still uncertain. Case presentation Cases involving six Caucasian patients with suspected MALA who were admitted to the emergency department were analysed. All these patients presented with pH values < 7.35, lactate levels > 2 mmol/L, and estimated glomerular filtration < 30 mL/min. Metformin plasma concentrations were > 2.5 mg/L in all the patients. The highest metformin concentrations were not found in the patients with the highest lactate levels. The anion gap values ranged from 12.3 to 39.3, with only two patients exhibiting values > 14. Conclusions In patients with MALA, there is a significant variability in the anion gap values, which is not related to the level of metformin accumulation, and therefore, it is doubtful whether measuring anion gaps is useful as an approach for MALA diagnosis.

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Incidence and risk factors for hyperlactatemia in ED patients with acute metformin overdose

Cited by 6 publications

References 26 publications

Accuracy of prehospital point‐of‐care lactate in early in‐hospital mortality

Accuracy of prehospital point‐of‐care lactate in early in‐hospital mortality

Profound Metabolic Acidosis due to Metformin Intoxication Requiring Dialysis

The usefulness of measuring the anion gap in diagnosing metformin-associated lactic acidosis: a case series

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