MALA first line of Mx

 Q: 64 years old male is admitted to ICU after accidental ingestion of metformin. Patient is found to be in severe metabolic acidosis with a PH of 7.08. Patient should receive activated charcoal? 

A) Yes

B) No

Answer: A

Metformin-associated Lactic Acidosis (MALA) is a potentially a fatal condition. As a first line of treatment, all patients with acute ingestion should receive activated charcoal, if they can tolerate it or there is no contraindication otherwise. The recommended dose is 1 gm/kg but as a rule of thumb, all patients can just be given 50 grams once. 

The patients who are in severe lactic acidosis, hemodialysis is a life-saving treatment, but it takes time and effort to arrange hemodialysis. 

In between patient can be treated with a soda-bicarb bolus followed by infusion to avoid hemodynamic collapse from severe acidosis. The usual cut-off point is at the PH of 7.10 or at the clinician's discretion. In an adult patient, the dose is 1-2 meq/kg bolus followed by 133-150 meq in one liter of D5W at a rate of 250 mL/hour.

#toxicology

Reference:

Moioli A, Maresca B, Manzione A, Napoletano AM, Coclite D, Pirozzi N, Punzo G, Menè P. Metformin associated lactic acidosis (MALA): clinical profiling and management. J Nephrol. 2016 Dec;29(6):783-789. doi: 10.1007/s40620-016-0267-8. Epub 2016 Jan 22. PMID: 26800971.