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Metformin is a widely prescribed, oral, anti-diabetic agent for the treatment of type 2 diabetes mellitus (DM2). While generally well-tolerated, metformin can accumulate in patients with acute kidney injury (AKI) or chronic kidney disease (CKD), leading to potentially life-threatening complications such as metformin-associated lactic acidosis (MALA). Severe hyperkalemia is a rare but serious manifestation of metformin toxicity.

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In patients with diabetes, diabetic ketoacidosis (DKA) is a well-documented potential complication, usually presenting with hyperglycemia, anion gap acidosis, and positive ketones. Metformin toxicity in the setting of acute renal failure is also a well-known cause of lactic acidosis. However, metformin-induced euglycemic ketoacidosis is less well-known or studied.

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Metformin toxicity is a life-threatening condition with high morbidity and mortality. Toxicity predominantly occurs in the setting of acute renal dysfunction, as the drug is solely eliminated by the kidneys. While this risk is widely known to clinicians, diagnosing metformin toxicity is challenging because commercially available serum metformin levels require days to weeks to result.

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Methylene Blue in Metformin Intoxication: Not Just Rescue But Also Initial Treatment.

Pediatr Emerg Care

November 2024

From the Departmant of Intensive Care Medicine, Mersin City Training and Research Center, Mersini Turkey.

Metformin (MTF) is a widely used oral antidiabetic medication. Regardless the reason, high doses of MTF cause lactic acidosis as a result of its effects on mitochondrial ATP production and no-mediated vascular smooth muscle relaxation. Metformin-associated lactic acidosis can be life-threatening despite all treatments.

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High risk and low prevalence diseases: Metformin toxicities.

Am J Emerg Med

October 2023

Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA. Electronic address:

Introduction: Metformin toxicity is a rare but serious condition that carries with it a high rate of morbidity and mortality.

Objective: This review highlights the pearls and pitfalls of metformin toxicity, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence.

Discussion: Metformin is a common medication used for treatment of diabetes mellitus.

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