1.
Osmolar-gap in the setting of metformin-associated lactic acidosis: Case report and a literature review highlighting an apparently unusual association.
Elshafei, MN, Alamin, M, Mohamed, MFH
Medicine. 2020;(41):e22492
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Abstract
RATIONALE Metformin-associated lactic acidosis (MALA) is a rare adverse effect that has significant morbidity and mortality. MALA is a high anion gap (AG), nonosmolar acidosis. Associated osmolar-gap (OG) is rarely reported, so finding an OG may make the diagnosis of MALA challenging. PATIENT CONCERNS Forty-five years' old type II diabetic patient on metformin presented to emergency with a two-day history of vomiting, watery diarrhea, and mild abdominal discomfort. On examinations, he looked dehydrated. Investigation revealed acute kidney injury (AKI) with a high lactic acid (LA) level of 24 mmol/L, pH of 6.8, AG of 40, and an OG of 20 mOsm/kg DIAGNOSES The presence of an OG made the diagnosis challenging; the history was negative for alcohol, osmolar substance, or illicit drug ingestion or use. The toxicology screen was negative. After ruling out plausible causes of AG and OG, MALA was deemed the likely reason for his presentation likely precipitated by dehydration and AKI. INTERVENTIONS He underwent two sessions of hemodialysis, afterward managed with fluid hydration. OUTCOMES On day 3, he was in the polyuric phase suggestive of acute tubular necrosis. His serum creatinine improved afterward with improved acidosis; after 8 days, he was discharged in stable condition. LESSONS MALA is a rare side effect of metformin therapy. Acute kidney injury is a known precipitant of MALA. In our review, we highlight the association of MALA and the presence of an OG. We believe that treating physicians should be aware of this relationship to avoid delaying or overlooking such an important diagnosis.
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Is an SGLT2 inhibitor right for your patient with type 2 diabetes?
Lisenby, KM, Meyer, A, Slater, NA
The Journal of family practice. 2016;(9):587-93
Abstract
Metformin isn't quite doing the job or is contraindicated? Here's a look at the patients who may benefit from these agents and the monitoring required.
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JCL roundtable: Clinical management of individuals with obesity.
Brown, WV, Bays, H, Bray, GA
Journal of clinical lipidology. 2014;(3):237-48
Abstract
Our topic is the evaluation and treatment of obesity in the practice of medicine. I am joined by Dr. Harold Bays who has carried out many studies of dietary and medical interventions in patients with obesity. I am also honored to have Dr. George Bray who is known for his many years of research into causes of obesity and its therapy. Our goal is bring this clinical and research experience to bear on the office practice of medicine.
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[Sequential treatment with insulin glargine and metformin, and exenatide in a patient with newly diagnosed type-2 diabetes].
Kress, S
Deutsche medizinische Wochenschrift (1946). 2010;(18):907-10
Abstract
UNLABELLED HISTORY AND ADMISSIONS FINDINGS A 54-year-old man was admitted to hospital for treatment of a newly diagnosed type 2 diabetes. He had polydipsia and polyuria and had lost 11 kg in weight over four weeks. Further diagnoses were visceral obesity and arterial hypertension. INVESTIGATIONS Laboratory tests revealed highly elevated blood glucose parameters (HbA1c 14,9 %, fasting glucose 280 mg/dl, maximal postprandial glucose 430 mg/dl and 320 mg/dl before the meal) and triglyceride (2219 mg/dl). TREATMENT AND COURSE The patient was initially treated with a combination of insulin glargine and metformin. After a few days exenatide was added, as the patient wanted to be able to go without insulin. He was given a structured diabetes education and motivated to have five to six hours' of physical activity and a low glycemic diet. After a few days normal glucose levels had been achieved. After one month the insulin treatment was discontinued. The continuing treatment with metformin, 1000 mg twice daily, and exenatide, 5 mg twice daily, prolonged remission of beta-cell dysfunction and maintained normal blood glucose levels for seven months. After reduction of the metformin dosage (500 mg twice daily) and discontinuance of exenatide as well as a reduction of his physical activity (because of joint pain) for six months, the glucose control worsened. When exenatide was administered again, good control of postprandial blood glucose, but not of fasting glucose was achieved. CONCLUSIONS Initial combination treatment with insulin glargine, metformin and exenatide may be beneficial in a subgroup of patients with newly diagnosed type 2 diabetes, markedly elevated blood glucose and free fatty acid levels (glucolipotoxicity). This should be further investigated in randomized controlled trials.