Critical Care: Student/Resident Case Report Poster - Critical Care V |

Doctor’s Orders: A Case of Unintentional Overtreatment FREE TO VIEW

Rebecca Wetzel, DO; Brett Sadowski, MD; Dustin Little, MD
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Walter Reed National Military Medical Center, Rockville, MD

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):461A. doi:10.1016/j.chest.2016.08.474
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care V

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Metformin is proven, first-line therapy for diabetes mellitus that is generally well tolerated. Albeit rare, lactic acidosis is the most feared complication as it is associated with substantial mortality. Monitoring patient’s renal function is critical to decreasing the risk of this serious consequence. We present a case of a patient without a history of kidney disease whose preceding illness led to a rapid decline in renal function and a severe and life-threatening acidosis.

CASE PRESENTATION: A 77 year old male with diabetes (last A1c 6.5), hypertension, and dementia presented to the ED with a five day history of diarrhea, vomiting, and confusion. The week prior he had been diagnosed with a urinary tract infection and was on antibiotics. Initial exam was unremarkable and vital signs were stable, however laboratory work demonstrated an elevation of creatinine to 8.8 (baseline 1.0), a pH of 7.09, a lactic acid level of 17.3 and bicarbonate level of 5. He underwent an exhaustive evaluation for causes of the renal failure, lactic acidosis, and his compensated, acute, anion gap metabolic acidosis. He was covered broadly in the event of underlying sepsis from a urinary source as well as empiric treatment Clostridium difficile infection. He rapidly improved with supportive treatment that included bicarbonate therapy. Given this improvement and the retrospective finding of a metformin level more than twice the therapeutic range, his acidosis was attributed to his continued use of metformin during an acute kidney injury from dehydration secondary to a diarrheal illness.

DISCUSSION: Metformin associated lactic acidosis (MALA) is a serious, life-threatening condition associated with up to 40% mortality if not aggressively treated. As lactate is eliminated unaltered through renal excretion, use of hemodialysis, continuous renal replacement therapy (CRRT), and infusions of bicarbonate have been reported as treatments with variable success. With an estimated 1-7% of hospital admissions directly associated with acute kidney injury, it is unsurprising that metformin associated lactic acidosis has been implicated in 0.84% of intensive care admissions.

CONCLUSIONS: Metformin therapy has not been shown to have a mortality benefit in patients over 65 and is actually an independent risk factor for mortality in elderly patients with chronic renal failure. This case serves as a reminder for all clinicians that iatrogenic lactic acidosis associated with metformin use rapidly develops into life-threatening illness and that the continued use of the drug should be re-assessed on every clinical encounter.

Reference #1: Peters, Nicolas et al. “Metformin-Associated Lactic Acidosis in an Intensive Care Unit.” Critical Care 12.6 (2008): R149. PMC. Web.

Reference #2: Chang, Flora, et al. “Use of Renally Inappropriate Medications in Older Veterans: A National Study.” Journal of the American Geriatrics Society J Am Geriatr Soc 63.11 (2015): 2290-297. Web.

DISCLOSURE: The following authors have nothing to disclose: Rebecca Wetzel, Brett Sadowski, Dustin Little

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