MALA prognostic factors

  Q: All of the following are found to be correlated to mortality in Metformin Associated Lactic Acidosis (MALA) EXCEPT? (select one)

A) Lower PH  

B) High lactate 

C) Increase INR 

D) Metformin level 

E) High associated comorbidities 

 Answer: D 

MALA carries a high mortality, up to 50 percent despite the best available treatment. From the available case-series, it appears that deteriorated liver function manifested by high INR is the best predictor of mortality in MALA (choice C). 

There are conflicting reports regarding correlation of death with level of lactic acidosis in PH (Choices A and B). 

Interestingly, most studies failed to show any correlation between absolute metformin level and mortality in MALA (choice D). 

It is assumed that the sicker the patient at baseline, the lower would be the chances of survival (choice E).

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References: 

1. Vecchio S, Giampreti A, Petrolini VM, et al. Metformin accumulation: lactic acidosis and high plasmatic metformin levels in a retrospective case series of 66 patients on chronic therapy. Clin Toxicol (Phila) 2014; 52:129. 

2. Lalau JD, Race JM. Lactic acidosis in metformin-treated patients. Prognostic value of arterial lactate levels and plasma metformin concentrations. Drug Saf 1999; 20:377. 

3. Seidowsky A, Nseir S, Houdret N, Fourrier F. Metformin-associated lactic acidosis: a prognostic and therapeutic study. Crit Care Med 2009; 37:2191. 

4.  Dell'Aglio DM, Perino LJ, Kazzi Z, et al. Acute metformin overdose: examining serum pH, lactate level, and metformin concentrations in survivors versus nonsurvivors: a systematic review of the literature. Ann Emerg Med 2009; 54:818.