Abstract
IntroductionMetformin is a commonly used treatment modality in type 2 diabetes mellitus, with a well documented side effect of lactic acidosis. In the intensive care setting lactate and pH levels are regularly used as a useful predictor of poor prognosis. In this article we highlight how high lactate levels are not an accurate predictor of mortality in deliberate metformin overdose.Case presentationWe present the case of a 70-year-old Caucasian man who took a deliberate metformin overdose of unknown quantity. He had a profound lactic acidosis at presentation with a pH of 6.93 and a lactate level of more than 20mmol/L. These figures would normally correspond with a mortality of more than 80%; however, with appropriate management this patient’s condition improved.ConclusionWe provide evidence that the decision to treat severe lactic acidosis in deliberate metformin overdose should not be based on arterial lactate and pH levels, as would be the case in other overdoses. We also demonstrate that appropriate treatment with hemodiafiltration and 8.4% sodium bicarbonate, even in patients with a very high lactate and low pH, can be successful.
Highlights
Metformin is a commonly used treatment modality in type 2 diabetes mellitus, with a well documented side effect of lactic acidosis
We provide evidence that the decision to treat severe lactic acidosis in deliberate metformin overdose should not be based on arterial lactate and pH levels, as would be the case in other overdoses
We present a case of deliberate metformin overdose in which a patient presenting with an arterial lactate of more than 20mmol/L
Summary
This case report highlights that there is much evidence showing that hyperlactatemia is a very poor prognostic indicator, this does not necessarily apply to patients who take a deliberate metformin overdose. Based on this case and recent research, the decision to treat (or not to treat) a patient with severe lactic acidosis with metformin ingestion cannot be based on the arterial lactate and pH, as would be the case in sepsis or amitriptyline overdose. Authors’ information ST, Foundation Year 1, Intensive Care Unit, Lincoln County Hospital. Author details 1Intensive Care Unit, Lincoln County Hospital, Lincoln LN2 5QY, UK. Author details 1Intensive Care Unit, Lincoln County Hospital, Lincoln LN2 5QY, UK. 2Queens Medical Centre, Nottingham University Medical School, Nottingham, UK
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