Atilla ŞENCAN, Tayfun ADANIR, Aynur ATAY, Aslı A. ATASOY, MURAT AKSUN, Güneş TERZİ, Nagihan KARAHAN

Suisid girişimi sonrası yüksek anyon açığı olan metabolik asidoz: metformin entoksikasyonu

Metformin ilişkili laktik asidoz metformin zehirlenmesi olgularında mortalitesi yüksek olan yan etkilerden birisidir. Literatürde metformin ile suisid girişimi çok az vakada tanımlanmıştır. Bizde suisid amaçlı akut metformin zehirlenmesi tanısı alan üç genç olguyu sunmayı amaçladık. Her üç olgunun da zehirlenme bulguları hemodiyaliz, destek tedavisi ve mekanik ventilator desteği ile başarılı bir şekilde tedavi edilirken, 2. hasta gecikmiş tanı nedeni ile trakeotomili spontan solunumda ve bilinçsiz olarak taburcu edildi. Acil serviste, suisid amaçlı ilaç alımından sonra yüksek anyon açıklı metabolik asidoz varlığı olan hastalarda metformin intoksikasyonu düşünülmelidir. Erken tanı ve hemodiyaliz veya hemofiltrasyon yöntemleri ile metabolik asidozun hızlı düzeltilmesi, destek tedavisi ve kan glukoz düzeyinin sürdürülmesi pozitif sonuçlara neden olacaktır.

High anion gap metabolic acidosis after suicide: metformin intoxication

Metformin associated lactic acidosis (MALA) is one of the most deadly side effects in metformin intoxication. Only a few cases of deliberate self-poisoning with metformin have been described in the literature. We report three young patients who took a large dose of metformin in an attempt to suicide. All of the patients were successfully treated with hemodialysis, adequate hemodynamic and ventilatory support. One of the patients was externed with unconsciously and spontaneous breathing with tracheotomy, because of delayed diagnosis. Metformin intoxication should be suspected when patients presented by high anion gap metabolic acidosis after suicide attempt by ingesting drugs. Early diagnosis and rapid correction of metabolic acidosis using hemodialysis or hemofiltration, supportive therapy and maintenance of blood glucose provide the possibility of a positive outcome.

PDF

___

1.Misbin RI. Phenformin-associated lactic acidosis: pathogenesis and treatment. Ann Intern Med. 1977 Nov;87(5):591~5.
2.Wysowski DK, Armstrong G, Govemale L. Rapid increase in the use of oral antidiabetic drugs in the United States, 1990-2001. Diabetes Care. 2003 Jun; 26(6): 1852-5.
3.Garber AJ. Metformin: mechanisms of antihyperglycemic action, other pharmacodynamic properties, and safety perspectives. Endocr Pract. 1997 Nov-Dec; 3(6): 359-70.
4.Scheen AJ. Qinical pharmacokinetics of metformin. Clin Pharmacokinet. 1996 May; 30(5): 359-71.
5.Robert F, Fendri S, Hary L, Lacroix C, Andrejak M, Lalau JD : Kinetics of plasma and erythrocyte metformin after acute administration in healthy subjects. Diabetes Metab. 2003 Jun; 29(3): 279-83.
6.Dunn CJ, Peters DH. Metformin: A review of its pharmacological properties and therapeutic use in non-insulin-dependent diabetes mellitus. Drugs. 1995 May; 49(5): 721-49.
7.Spiller HA, Sawyer TS. Toxicology of oral antidiabetic medications. Am J Health Syst Pharm. 2006 May 15;63(10):929-38.
8.Misbin RI, Green L, Stadel BV, Gueriguian JL, Gubbi A, Fleming GA. Lactic acidosis in patients with diabetes treated with metformin. N Eng J Med. 1998 Jan 22; 338(4):265-6.
9.Stang M, Wysowski DK, Butler-Jones D. Incidence of lactic acidosis in metformin users. Diabetes Care. 1999 Jun; 22(6): 925-7.
10.Bailey CJ. Biguanides and NIDDM. Diabetes Care. 1992 Jun; 15(6):755-72.
11.Jurovich MR, Wooldridge JD, Force RW. Metformin-associated nonketotic metabolic acidosis. Ann Pharmacother. 1997 Jan; 31(l):53-5.
12.Lalau JD, Lacroix C, Compagnon P, de Cagny B, Rigaud JP, Bleichner G, et al. Role of metformin accumulation in metformin-associated lactic acidosis. Diabetes Care. 1995 Jun; 18(6):779-84.
13.Lalau JD, Lacroix C, De Cagny B, Fournier A. Metformin-associated lactic acidosis in diabetic patients with acute renal failure. A critical analysis of its pathogenesis and prognosis. Nephrol Dial Transplant. 1994;9 Suppl 4:126-9.
14.Berner B, Hummel KM, Strutz F, Ritzel U, Ramadori G, Hagenlocher S, et al. Metformin-associated lactic acidosis with acute renal failure in type 2 diabetes mellitus. Med Klin (Munich). 2002 Feb 15;97(2):99-103.
15.Heaney D, Majid A, Junor B. Bicarbonate haemodialysis as a treatment of metformin overdose. Nephrol Dial Transplant. 1997 May; 12(5): 1046-7.
16.Luft D, Schmülling RM, Eggstein M. Lactic acidosis in biguanid-treated diabetics: a review of 330 cases. Diabetologia. 1978 Feb; 14(2):75-87
17.Panzer U, Kluge S, Kreymann G, Wolf G. Combination of intermittent haemodialysis and high-volume continuous haemofiltration for the treatment of severe metformin-induced lactic acidosis. Nephrol Dial Transplant. 2004 Aug; 19(8):2157-8
18.Harvey B, Hickman C, Hinson G, Ralph T, Mayer A. Severe lactic acidosis complicating, metformin overdose successfully treated with high-volume venovenous hemofiltration and aggressive alkalinization. Pediatr Crit Care Med. 2005 Sep;6(5):598-601.
19.Guo PY, Storsley LJ, Finkle SN. Severe lactic acidosis treated with prolonged hemodialysis: recovery after massive overdoses of metformin. Semin Dial. 2006 Jan-Feb;19(l):80-3.