From the Guidelines
Management of metformin-induced lactic acidosis requires immediate discontinuation of metformin and aggressive supportive care, with hemodialysis being the cornerstone of treatment. The most recent and highest quality study 1 emphasizes the importance of avoiding metformin in patients at risk for lactic acidosis, such as those with significant renal impairment or impaired lactic acid clearance. Initial management includes:
- Securing the airway, ensuring adequate breathing and circulation
- Administering intravenous fluids to correct volume depletion and improve tissue perfusion
- Considering sodium bicarbonate for severe acidosis (pH < 7.1)
- Initiating hemodialysis promptly to remove metformin and lactate
- Using continuous renal replacement therapy (CRRT) in hemodynamically unstable patients
- Employing vasopressors like norepinephrine for persistent hypotension Key considerations include:
- Identifying and treating the underlying trigger for lactic acidosis, such as sepsis, hypoxemia, or acute kidney injury
- Monitoring vital signs, arterial blood gases, lactate levels, and electrolytes closely
- Withdrawing metformin if increased lactate concentrations are apparent, especially in fragile patients
- Discontinuing metformin in patients at risk for lactic acidosis, such as those with acute kidney injury, hypoxia, or shock 1.
From the FDA Drug Label
If metformin-associated lactic acidosis is suspected, general supportive measures should be instituted promptly in a hospital setting, along with immediate discontinuation of metformin hydrochloride tablets In metformin hydrochloride tablets treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin
The management of metformin-induced lactic acidosis involves:
- Immediate discontinuation of metformin hydrochloride tablets
- General supportive measures in a hospital setting
- Prompt hemodialysis to correct the acidosis and remove accumulated metformin 2
From the Research
Management of Metformin-Induced Lactic Acidosis
The management of metformin-induced lactic acidosis involves several key steps:
- Immediate cessation of metformin therapy 3, 4
- Supportive management, including treatment of any underlying conditions that may be contributing to the lactic acidosis, such as sepsis or diabetic ketoacidosis 3, 5
- Correction of acidosis, electrolyte alterations, and fluid balance, which can be achieved through continuous renal replacement therapy (CRRT) in cases of severe lactic acidosis complicated by acute kidney injury 4, 5
- Extracorporeal removal of metformin, which can be achieved through intermittent hemodialysis or CRRT in severe cases 3, 5
Risk Factors and Prevention
Several risk factors can contribute to the development of metformin-induced lactic acidosis, including:
- Renal impairment, which can reduce the clearance of metformin 3, 4
- Excessive alcohol consumption, which can contribute to lactic acidosis by consuming nicotinamide adenine dinucleotides required for lactate metabolism 3
- Concomitant use of certain medications, such as histamine-2 receptor antagonists or ribociclib, which can reduce renal elimination of metformin 3
- Acute disease states leading to tissue hypoxia, such as sepsis or acute kidney injury 4, 6 Prevention of metformin-induced lactic acidosis is crucial, and patients should be aware of the risks and symptoms, including vomiting and diarrhea, which can be a clear sign of lactic acidosis 6
Treatment Outcomes
Treatment outcomes for metformin-induced lactic acidosis can vary, but prompt recognition and initiation of treatment, including CRRT, can lead to rapid recovery and improved survival rates 5. However, some patients may experience sequelae, such as permanent neurological damage or death 7, 5.