From the Guidelines
Hyperlactatemia in diabetic patients requires immediate attention to prevent lactic acidosis, and metformin should be discontinued or avoided in such cases.
Treatment Approach
- In patients with hyperlactatemia, metformin should be withdrawn to prevent further increase in lactate levels, as it may exacerbate lactic acidosis 1.
- Insulin therapy should be considered as part of the treatment plan, especially if hyperglycemia is severe or if catabolic features are present 1.
- Alternative glucose-lowering agents, such as sulfonylureas, GLP-1 RAs, or dual GIP and GLP-1 RAs, may be used to manage hyperglycemia in patients with hyperlactatemia 1.
- Monitoring of kidney function is crucial, and metformin should be avoided or discontinued in patients with significant renal impairment (eGFR < 30 mL/min/1.73 m²) 1.
Key Considerations
- Lactic acidosis risk is increased in patients with renal impairment, liver disease, or those undergoing iodinated contrast imaging procedures, and metformin should be used with caution in these cases 1.
- Vitamin B12 deficiency is a potential side effect of long-term metformin use, and periodic testing of vitamin B12 levels may be necessary 1.
- Gastrointestinal intolerance is a common side effect of metformin, and gradual dose titration or use of extended-release formulation may help mitigate these effects 1.
From the Research
Treatment for Diabetic Patients with Hyperlactatemia
The treatment for diabetic patients with hyperlactatemia involves several key steps:
- Immediate cessation of metformin, as it may reduce lactate clearance and exacerbate lactic acidosis 2
- Supportive management, including treatment of any underlying conditions that may be contributing to the hyperlactatemia, such as sepsis or diabetic ketoacidosis 2, 3
- Renal replacement therapy, such as intermittent hemodialysis or continuous kidney replacement therapy, may be necessary in severe cases of metformin-associated lactic acidosis (MALA) 2, 4, 3
- Monitoring of lactate levels and renal function, as well as adjustment of treatment as needed 2, 4
Factors Contributing to Hyperlactatemia
Several factors can contribute to the development of hyperlactatemia in diabetic patients, including:
- Metformin use, particularly in patients with renal impairment or other factors that reduce metformin clearance 2, 5, 4
- Sepsis or septic shock, which can increase lactate production and reduce clearance 5, 4
- Ischemia or hypoxia, which can increase lactate production 5
- Neoplasia, which can increase lactate production 5
- Excessive alcohol consumption, which can reduce lactate clearance 2
Prognosis and Mortality
The prognosis and mortality for diabetic patients with hyperlactatemia vary depending on several factors, including:
- The severity of the hyperlactatemia, with higher lactate levels associated with increased mortality 5, 4
- The presence of underlying conditions, such as sepsis or diabetic ketoacidosis, which can increase mortality 5, 4
- The effectiveness of treatment, including renal replacement therapy and supportive management 2, 4, 3