Background: Metformin is a widely prescribed medication for the management of type 2 diabetes. It is known to have a high safety index, however it can cause serious adverse effects such as lactic acidosis, particularly in patients with chronic kidney disease. Elderly patients are at higher risk of developing Metformin-Associated Lactic Acidosis (MALA) due to aging kidney. We aim to highlight the importance of early adjustment of metformin and propose development of guidelines with higher estimated glomerular filtration rate (eGFR) for deprescribing metformin in older adults in contrast to younger population. 

Case Presentation: An 82 year old male with a past medical history of Diabetes, Chronic kidney disease 2, Atrial fibrillation on apixaban, Stroke and Chronic stage 4 sacral decubitus ulcer was sent to the emergency department (ED) for altered mental status. He was admitted to the intensive care unit for management of septic shock, PEA cardiac arrest and acute hypoxemic respiratory failure requiring intubation. Labs showed lactic acidosis and anion gap metabolic acidosis in the setting of no infectious source. Patient had chronic kidney disease with acute renal failure on metformin. He was diagnosed with Metformin Associated Lactic Acidosis. 

Discussion: This case highlights the potential risks associated with metformin use in older adults with CKD and AKI from infections, dehydration and decreasing oral intake due to acute illness, aging or dementia. There are expected physiological changes in the aging kidney including cellular dysfunction and nephrosclerosis that can cause unexpected kidney injury in older adults causing their eGFR to drop acutely. Age-related changes in renal function and decreased clearance of drugs place elderly patients at higher risk of developing MALA. New guidelines for higher eGFR for deprescribing metformin should be considered in older adults. This could prevent morbidity, mortality and adverse outcomes in the frail older diabetic population. 


Metformin Associated Lactic Acidosis in an Elderly Patient: A Case Report

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