Metabolic Acidosis – Not Always the Medication to Blame

Abstract

Background: Metabolic acidosis is a clinical disturbance characterized by an increase in acidity of plasma. Metabolic acidosis is considered a sign of an underlying disease. Identification of this underlying condition is the cornerstone to initiate appropriate management. Metabolic acidosis is typically classified as having a normal anion gap (AG) (i.e. non-AG) or a high AG. An increase in the AG can result from either a decrease in unmeasured cations (e.g. hypokalemia, hypocalcemia, hypomagnesemia) or an increase in unmeasured anions (e.g. hyperphosphatemia, high albumin levels). Case: A 46-year-old male with a history of type 2 diabetes mellitus, recently started on liraglutide. He was presented to the emergency department with 4 days of nausea, vomiting, and diarrhea and one day of lethargy. He appeared to be dyspneic upon presentation, and he was initially placed on noninvasive positive pressure ventilation. The arterial blood gases (ABG), however, showed metabolic acidosis. After admission and resolution of diabetic ketoacidosis, his bicarbonate was still low, and a sodium bicarbonate drip was begun. Correction only had occurred after stopping liraglutide. Conclusion: Vehicle solvent such as propylene glycol should be considered in the differential diagnosis of high anion gap metabolic acidosis, and its level should be measured in intractable cases.