Methylene blue as treatment for vasoplegic shock in severe metformin overdose: A case report

Workum, Jessica D.; Keyany, A; Jaspers, Tessa

doi:10.1016/j.toxrep.2023.07.005

Cited by 4 publications

(5 citation statements)

References 12 publications

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“…10 Although some received a sustained or second dose, it must be noted that high doses (up to 7 mg/kg) can reduce abdominal blood flow. 11 The blood metformin concentrations in two of the above‐mentioned cases 8 , 9 were four to five times higher than that of ours, suggesting that blood metformin levels may not be correlated with disease severity. Tallman et al.…”

Section: Discussioncontrasting

confidence: 69%

“…Although there is some theoretical support for MB therapy for metformin poisoning, its clinical utility and the optimal administration protocols are not well established. A PubMed search for “metformin, methylene blue” only yielded four case reports in English 6 , 7 , 8 , 9 (Table 1 ). In those cases, MB was mainly used to save patients in severe vasoplegic shock that were unresponsive to extreme catecholamine doses.…”

Section: Discussionmentioning

confidence: 99%

“… 8 Workum et al. 9 detailed MB administration in a case involving a concurrent hepatotoxic drug overdose, which resulted in liver necrosis. Thus, MB may be life‐saving in patients with severe metformin toxicity when other options are unavailable, but excessive doses should be avoided.…”

Section: Discussionmentioning

confidence: 99%

“…also reported that the administration of MB 33 h after arrival, combined with early blood purification therapy, effectively countered the toxic effects of metformin. 9 This suggests the potential efficacy of MB in combating the toxic effects of metformin, regardless of the time elapsed since the ingestion of metformin, and even when the patient's metformin blood concentration is expected to have decreased, as long as metabolic disturbances and circulatory insufficiency persist. Nevertheless, this is not beyond our theory, as we could not find any related articles in a PubMed search.…”

Section: Discussionmentioning

confidence: 99%

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Successful use of methylene blue for catecholamine‐refractory vasoplegic shock due to metformin intoxication: A case report and literature review

Takahashi,

Nakano,

Motoki

et al. 2024

Acute Medicine & Surgery

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BackgroundSevere metformin intoxication can lead to lactic acidosis and vasoplegic shock, for which the optimal management strategy remains uncertain, especially in cases of severe circulatory collapse.Case PresentationA 45‐year‐old diabetic woman on metformin therapy presented with impaired consciousness and seizures. She had experienced a cardiac arrest and undergone extracorporeal cardiopulmonary resuscitation. Blood gas analysis showed severe lactic acidosis. A 71‐g metformin packet was found at the patient's home, suggesting an overdose. Despite extracorporeal support and blood purification, severe lactic acidosis and hypotension persisted. Methylene blue was administered 32 h from the onset, which improved her metabolic and circulatory status. We examined her blood sample throughout the case to check the transition of metformin blood concentration.ConclusionMethylene blue may be beneficial for severe metformin toxicity, regardless of the blood concentration of metformin and the time since intoxication. However, further research is needed to establish its optimal use and effectiveness.

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Section: Discussioncontrasting

confidence: 69%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Successful use of methylene blue for catecholamine‐refractory vasoplegic shock due to metformin intoxication: A case report and literature review

Takahashi,

Nakano,

Motoki

et al. 2024

Acute Medicine & Surgery

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“…, noradrenaline, vasopressin[ 56 ]) and inotropes may be needed to maintain a mean arterial pressure ≥ 65 mmHg[ 31 ]. Intravenous methylene blue infusion has been reported in some case studies to reverse metformin-induced vasodilation, as it counters the activation of endothelial nitric oxide synthase by metformin[ 57 ]. Supplemental oxygen and mechanical ventilation may also be needed to maintain an arterial oxygen saturation of 94%-98%[ 58 ].…”

Section: Prevention and Treatment Of Malamentioning

confidence: 99%

Metformin-associated lactic acidosis: A mini review of pathophysiology, diagnosis and management in critically ill patients

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2024

World J Diabetes

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Metformin is a common diabetes drug that may reduce lactate clearance by inhibiting mitochondrial oxidative phosphorylation, leading to metformin-associated lactic acidosis (MALA). As diabetes mellitus is a common chronic metabolic condition found in critically ill patients, pre-existing metformin use can often be found in critically ill patients admitted to the intensive care unit or the high dependency unit. The aim of this narrative mini review is therefore to update clinicians about MALA, and to provide a practical approach to its diagnosis and treatment. MALA in critically ill patients may be suspected in a patient who has received metformin and who has a high anion gap metabolic acidosis, and confirmed when lactate exceeds 5 mmol/L. Risk factors include those that reduce renal elimination of metformin (renal impairment from any cause, histamine-2 receptor antagonists, ribociclib) and excessive alcohol consumption (as ethanol oxidation consumes nicotinamide adenine dinucleotides that are also required for lactate metabolism). Treatment of MALA involves immediate cessation of metformin, supportive management, treating other concurrent causes of lactic acidosis like sepsis, and treating any coexisting diabetic ketoacidosis. Severe MALA requires extracorporeal removal of metformin with either intermittent hemodialysis or continuous kidney replacement therapy. The optimal time to restart metformin has not been well-studied. It is nonetheless reasonable to first ensure that lactic acidosis has resolved, and then recheck the kidney function post-recovery from critical illness, ensuring that the estimated glomerular filtration rate is 30 mL/min/1.73 m2 or better before restarting metformin.

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2023

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Methylene blue as treatment for vasoplegic shock in severe metformin overdose: A case report

Cited by 4 publications

References 12 publications

Successful use of methylene blue for catecholamine‐refractory vasoplegic shock due to metformin intoxication: A case report and literature review

Successful use of methylene blue for catecholamine‐refractory vasoplegic shock due to metformin intoxication: A case report and literature review

Metformin-associated lactic acidosis: A mini review of pathophysiology, diagnosis and management in critically ill patients

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