{ "schemaVersion": 2, "eyebrow": "Critical Care", "title": "Lactic Acidosis", "summary": "Lactic acidosis requires parallel assessment for impaired oxygen delivery, regional ischemia, impaired clearance, and medication toxicity. Confirm acidemia with lactate elevation, identify reversible shock or ischemia immediately, and avoid attributing severe hyperlactatemia to metformin or catecholamines before competing causes are addressed.", "seoDescription": "Clinical approach to lactic acidosis: distinguish hypoperfusion, ischemia, impaired clearance, and medication-related hyperlactatemia to guide urgent management.", "clinicalQuestion": "How should clinicians rapidly classify and manage lactic acidosis while identifying tissue hypoxia, impaired clearance, and medication toxicity?", "specialty": "Critical Care Medicine", "audience": "U.S. physicians and medical trainees", "tags": [ "lactic acidosis", "hyperlactatemia", "metformin-associated lactic acidosis", "MALA", "anion gap metabolic acidosis", "shock", "tissue ischemia" ], "keyTakeaways": [ "Treat elevated lactate as a trigger to evaluate oxygen delivery, perfusion, regional ischemia, hepatic and renal clearance, and drug exposures; type A and type B mechanisms commonly coexist in critical illness. [18]", "Metformin-associated lactic acidosis is conventionally defined by recent metformin exposure with lactate greater than 5 mmol/L and pH below 7.35, but metformin use does not establish causality when sepsis, shock, hypoxia, or organ failure are present. [8][12][15]", "In a patient taking metformin, acute kidney injury, significant renal impairment, liver failure, hypovolemia, tissue hypoxia, and heavy alcohol use increase concern for metformin accumulation or impaired lactate clearance. [4][9][11][14]", "Do not use the anion gap as a screening substitute for a measured lactate concentration; the anion gap predicts lactate poorly in critical illness and may be distorted by hypoalbuminemia or hyperchloremia during resuscitation. [5][18]", "For suspected metformin-related lactic acidosis, immediately stop metformin, correct circulatory and acid-base derangements, and consider renal replacement therapy when clinically indicated to remove metformin and lactate and restore acid-base balance. [1][4]" ], "sections": [ { "id": "initial-priorities", "eyebrow": "Immediate Triage", "heading": "Act on lactate elevation before assigning a mechanism", "intro": "Classify the physiologic threat while testing for overlapping causes.", "paragraphs": [ "Obtain a blood gas, serum lactate, basic metabolic panel, glucose, and renal and hepatic indices when hyperlactatemia accompanies suspected metabolic acidosis. Lactic acidosis is characterized by acidemia with elevated lactate; one commonly used definition is pH below 7.35 with lactate greater than 2 mmol/L, whereas metformin-associated lactic acidosis uses lactate greater than 5 mmol/L with pH below 7.35 in the setting of metformin exposure. [12][15][16]", "Prioritize conditions in which lactate reflects inadequate oxygen delivery or regional ischemia: septic, cardiogenic, and hypovolemic shock; post-cardiac-arrest states; and limb or mesenteric ischemia. These type A processes require correction of the underlying perfusion or oxygenation deficit rather than treatment directed at lactate alone. [8][14][18]", "A serum bicarbonate below 10 mEq/L should broaden the immediate differential beyond isolated lactate elevation to severe ketoacidosis, toxic alcohol ingestion, severe limb or mesenteric ischemia, renal or hepatic failure, metformin-related acidemia, and multifactorial shock. Measure glucose and ketones and review toxicologic and medication exposures in parallel with resuscitation. [8]" ], "bullets": [ "If shock, hypoxemia, or a regional ischemic syndrome is present, manage that process as a presumptive type A driver while repeating lactate and acid-base measurements to assess trajectory. [14][18]", "If severe acidemia persists despite correction of the suspected driver, reassess for mixed mechanisms: ongoing ischemia, liver or kidney dysfunction, medication effect, ketoacidosis, or toxic ingestion. [8][18]", "Do not delay discontinuation of a potentially contributory drug, particularly metformin, while awaiting a metformin concentration. [4][8]" ], "subsections": [], "table": { "caption": "Actionable etiologic branches in lactic acidosis. [8][14][18]", "columns": [ "Clinical pattern", "Most actionable interpretation", "Immediate next step" ], "rows": [ [ "Shock, hypoxemia, post-arrest state, limb pain, or abdominal pain concerning for ischemia", "Type A lactic acidosis from tissue hypoperfusion, hypoxia, or regional ischemia is likely. [14][18]", "Correct the oxygen-delivery or perfusion deficit and urgently evaluate suspected limb or mesenteric ischemia. [8][14]" ], [ "No overt hypoperfusion; liver disease, malignancy, thiamine deficiency, ethanol exposure, total parenteral nutrition, HIV, or medication exposure", "Type B mechanisms increase lactate through altered metabolism or impaired clearance. [14][18]", "Review exposures and organ function; treat the identified driver rather than escalating resuscitation solely for lactate. [18]" ], [ "Metformin exposure plus acidemia and lactate greater than 5 mmol/L", "Meets conventional criteria for metformin-associated lactic acidosis; establish whether metformin accumulation, another systemic illness, or both are contributing. [8][12][15]", "Stop metformin, identify AKI, hypovolemia, sepsis, hypoxia, or liver failure, and consider renal replacement therapy when indicated. [4][8][11]" ], [ "Severe asthma receiving high-dose beta2-agonist therapy", "Bronchospasm-related hypoxia and increased work of breathing may coexist with beta2-agonist-associated type B hyperlactatemia. [6]", "Reassess oxygenation and airflow obstruction; avoid interpreting lactate alone as proof of progressive tissue hypoperfusion. [6]" ] ] } }, { "id": "interpret-lactate-and-gap", "eyebrow": "Laboratory Interpretation", "heading": "Use serial lactate and acid-base data, not the anion gap alone", "intro": "The gap supports a high-anion-gap process but does not identify its cause.", "paragraphs": [ "Calculate the anion gap to recognize unmeasured anions, but directly measure lactate whenever lactic acidosis is suspected. Ketoacidosis and lactic acidosis are common causes of an increased anion gap, yet serum anion gap has poor sensitivity for hyperlactatemia in critically ill patients. [5][19]", "Interpret a falling anion gap cautiously during resuscitation. Chloride-rich fluid administration and hypoalbuminemia can make the apparent anion gap improve even when the patient is clinically worsening or lactate metabolism remains impaired. [18]", "Trend lactate with the same attention given to perfusion, hemodynamics, oxygenation, and organ function. In septic shock cohorts, lactate clearance correlated with change in anion gap and was associated with 28-day mortality; this supports serial physiologic reassessment rather than a single lactate-based etiologic conclusion. [5]" ], "bullets": [ "An elevated anion gap with a low bicarbonate should prompt testing for both lactate and ketones rather than presuming one cause. [8][19]", "A normal or improving anion gap does not exclude clinically important hyperlactatemia, especially after saline-containing resuscitation or with hypoalbuminemia. [5][18]", "When lactate remains elevated, reassess for ongoing tissue ischemia, catecholamine exposure, renal or hepatic dysfunction, and medication-associated altered metabolism. [14][18][24]" ], "subsections": [], "table": { "caption": "Interpretive limits of common laboratory signals in suspected lactic acidosis. [5][18][19]", "columns": [ "Test or trend", "What it supports", "Pitfall that changes management" ], "rows": [ [ "Measured serum or blood lactate", "Direct evidence of hyperlactatemia. [23]", "Does not by itself distinguish impaired oxygen delivery from altered metabolism or impaired clearance. [14][18]" ], [ "Arterial or venous blood gas", "Defines acidemia and respiratory compensation; pH below 7.35 with lactate elevation supports lactic acidosis. [15][16]", "A pH value cannot establish whether metformin, shock, or a mixed process caused the lactate elevation. [8][18]" ], [ "Anion gap", "Supports accumulation of unmeasured anions, including lactate or ketones. [19]", "Predicts lactate poorly and may be distorted by hyperchloremia and hypoalbuminemia. [5][18]" ], [ "Serial lactate", "Helps assess whether the dominant physiologic disturbance is resolving. [5]", "Do not interpret nonclearance without reassessing ongoing shock, ischemia, clearance failure, and drugs. [18]" ] ] } }, { "id": "type-a-versus-type-b", "eyebrow": "Etiologic Classification", "heading": "Differentiate impaired oxygen delivery from altered metabolism and impaired clearance", "intro": "Use the classification to direct the next action, not to force a single-cause diagnosis.", "paragraphs": [ "Type A lactic acidosis is associated with tissue ischemia and anaerobic metabolism. Septic, cardiogenic, and hypovolemic shock, severe hypoxemia, and limb or mesenteric ischemia are high-priority causes because failure to reverse the underlying process can permit continued lactate generation. [14][18]", "Type B lactic acidosis occurs without overt tissue hypoperfusion or hypoxia and includes liver disease, malignancy, medications such as metformin and epinephrine, total parenteral nutrition, HIV, thiamine deficiency, trauma, excessive exercise, and ethanol intoxication. Liver and kidney dysfunction also matter because these organs normally contribute to lactate clearance. [7][14]", "Avoid treating type A and type B as mutually exclusive in an unstable patient. Critical illness can combine cellular ischemia, enhanced glycolysis, hepatic or renal impairment, and catecholamine infusion; the resulting lactate level may reflect several active mechanisms. [18]" ], "bullets": [ "A disproportionate lactate elevation without hypotension or other shock features should increase consideration of type B causes, but does not remove the need to exclude occult infection, hypoxia, or regional ischemia. [14][18]", "Catecholamine exposure can complicate lactate interpretation; epinephrine is a recognized type B cause, and beta2-agonists may increase lactate during acute severe asthma. [6][14][18]", "In acute severe asthma, persistent tachypnea after bronchodilator therapy may reflect lactate-associated acidosis as well as persistent bronchospasm; reassess airflow obstruction and oxygenation before escalating beta2-agonist dosing solely for respiratory rate. [6]" ], "subsections": [], "table": { "caption": "Clinical discriminators for major lactic acidosis mechanisms. [6][14][18]", "columns": [ "Mechanism", "Discriminating clues", "Management implication" ], "rows": [ [ "Tissue hypoperfusion or hypoxia", "Septic, cardiogenic, or hypovolemic shock; severe hypoxemia; post-arrest state. [8][14]", "Reverse the perfusion or oxygenation disorder and monitor serial lactate with clinical response. [5][18]" ], [ "Regional ischemia", "Limb or mesenteric ischemia can produce severe lactic acidemia and very low bicarbonate. [8][14]", "Urgently pursue definitive evaluation and correction of ischemia rather than attributing lactate to medication exposure. [8]" ], [ "Impaired clearance", "Liver failure or renal dysfunction, particularly when combined with systemic illness or metformin exposure. [4][7][11]", "Correct precipitating illness, stop contributing drugs, and consider renal replacement therapy when indicated for severe metformin-associated disease. [1][4]" ], [ "Medication-enhanced glycolysis or mitochondrial dysfunction", "Metformin, epinephrine, and high-dose beta2-agonist exposure are recognized contributors. [4][6][14]", "Remove or reduce the contributing exposure when clinically feasible while ensuring the primary disease is adequately treated. [4][6]" ] ] } }, { "id": "metformin-associated-lactic-acidosis", "eyebrow": "Medication Emergency", "heading": "Approach metformin-associated lactic acidosis as a mixed-cause syndrome", "intro": "Metformin exposure is clinically important but must not obscure shock, infection, or ischemia.", "paragraphs": [ "Suspect metformin-associated lactic acidosis when recent metformin exposure accompanies lactate greater than 5 mmol/L and pH below 7.35. A proposed more restrictive causal paradigm also requires a circulating metformin concentration above 5 mg/L, but metformin assays are often unavailable in emergency care and should not delay treatment. [8][12][15]", "Separate metformin-induced toxicity from metformin-associated acidemia due to another acute illness whenever possible. In a metformin user with sepsis, cardiac failure, hemorrhage, hypoxia, or renal failure, metformin may be an amplifier, a consequence of reduced clearance, or merely a concomitant medication; management must address all plausible contributors. [8][11]", "Immediately discontinue metformin and identify reversible precipitants: AKI or significant renal impairment, hypovolemia, hepatic dysfunction, tissue hypoxia, sepsis, heart failure, and heavy alcohol intake. Metformin inhibits mitochondrial complex I, reducing oxidative phosphorylation and shifting metabolism toward lactate production; renal dysfunction also impairs drug clearance. [4][9][11][14]" ], "bullets": [ "Avoid metformin in patients with anaerobic metabolism from sepsis or hypoxia, significant renal impairment, or liver failure that impairs lactate clearance. [11]", "Dose reduction is recommended at estimated GFR 30-45 mL/min/1.73 m2, and metformin should be discontinued when estimated GFR is below 30 mL/min/1.73 m2. [11]", "Do not use nonspecific gastrointestinal symptoms to exclude serious disease: nausea, vomiting, bloating, and diarrhea can occur in metformin-associated lactic acidosis. [13]", "Acute visual loss has been reported with profound metformin-associated acidemia, including reports at pH below 7.09; urgent correction of the metabolic emergency is the priority. [17]" ], "subsections": [ { "heading": "When to escalate to renal replacement therapy", "paragraphs": [ "For severe metformin-associated lactic acidosis, use renal replacement therapy when clinical severity warrants removal of metformin and lactate and correction of acid-base and electrolyte abnormalities. Hemodialysis has been reported to correct electrolyte abnormalities and lactic acidosis, although metformin has a large volume of distribution and the extent of removal may be uncertain. [1][4][17]" ], "bullets": [ "Continue management of sepsis, hypoxia, hypovolemia, or other precipitating illness during renal replacement therapy; extracorporeal therapy does not establish metformin as the sole cause of acidemia. [8][18]", "Monitor pH, bicarbonate, lactate, electrolytes, renal function, and the clinical trajectory after therapy because mixed mechanisms may persist. [1][4][18]" ] } ], "table": { "caption": "Metformin exposure: decision points in lactic acidosis. [4][8][11][12][15]", "columns": [ "Finding", "Interpretation", "Action" ], "rows": [ [ "Metformin exposure, lactate greater than 5 mmol/L, pH below 7.35", "Conventional metformin-associated lactic acidosis definition is met. [12][15]", "Stop metformin and urgently evaluate for AKI, hypovolemia, sepsis, hypoxia, liver failure, and ischemia. [4][8][11]" ], [ "Metformin level above 5 mg/L, lactate greater than 5 mmol/L, pH below 7.35", "Supports a proposed metformin-causal diagnostic paradigm. [8]", "Treat as severe metformin-related toxicity while managing concurrent systemic causes. [8]" ], [ "Estimated GFR 30-45 mL/min/1.73 m2", "Metformin dose reduction is recommended. [11]", "Review dose and renal trajectory; avoid accumulation during acute illness. [11]" ], [ "Estimated GFR below 30 mL/min/1.73 m2", "Metformin should be discontinued. [11]", "Stop metformin and select non-metformin glycemic management as clinically appropriate. [11]" ] ] } }, { "id": "treatment-and-monitoring", "eyebrow": "Management", "heading": "Correct the cause and monitor for failure of physiologic reversal", "intro": "Alkali and extracorporeal therapy are adjuncts, not substitutes for cause control.", "paragraphs": [ "Direct treatment at the dominant cause of lactate generation or impaired clearance. In shock or ischemia, restore oxygen delivery and correct the precipitating process; in drug-associated hyperlactatemia, withdraw or reduce the contributing exposure when clinically feasible; in metformin-associated disease, stop metformin and correct circulatory, electrolyte, and acid-base abnormalities. [4][6][14][18]", "Do not reflexively administer bicarbonate for every lactic acidosis. In diabetic ketoacidosis with metabolic acidosis, bicarbonate is described as unnecessary when hydration and reduction of blood glucose will correct the acidosis; by contrast, severe toxic or renal failure-associated metabolic acidosis may require alkali or renal replacement therapy. [1][3]", "Use serial lactate, pH, bicarbonate, electrolytes, renal function, and clinical perfusion to determine whether the chosen intervention is working. A biochemical improvement in anion gap alone is insufficient when hyperchloremia, hypoalbuminemia, persistent ischemia, or impaired clearance may conceal ongoing physiologic deterioration. [5][18]" ], "bullets": [ "Escalate the diagnostic search when lactate fails to fall in parallel with improvement in the presumed driver; reconsider occult regional ischemia, persistent shock, hepatic or renal clearance failure, ketoacidosis, toxic ingestion, and medication effects. [8][18]", "In severe metformin-associated disease, consider renal replacement therapy as part of the corrective strategy for lactate, acid-base, and electrolyte abnormalities. [1][4]", "In severe asthma with elevated lactate during intensive beta2-agonist treatment, reassess bronchodilator intensity in the context of airflow obstruction and oxygenation; lactate-associated tachypnea can otherwise be mistaken for worsening asthma. [6]" ], "subsections": [], "table": { "caption": "Monitoring signals that should trigger reassessment. [5][8][18]", "columns": [ "Observed course", "What it may mean", "Next clinical action" ], "rows": [ [ "Lactate declines with improved perfusion and clinical stabilization", "The corrected circulatory or oxygenation disturbance was likely an important driver. [5][18]", "Continue treatment of the underlying illness and serial physiologic monitoring. [5]" ], [ "Lactate remains elevated despite apparent hemodynamic improvement", "Mixed type A and type B mechanisms, ongoing regional ischemia, organ dysfunction, or medication effect may persist. [8][18]", "Reevaluate ischemia, drug exposures, renal and hepatic function, ketoacidosis, and toxicologic causes. [8][18]" ], [ "Anion gap falls but acidosis or clinical instability persists", "Hyperchloremia or hypoalbuminemia may make the gap misleading. [18]", "Rely on blood gas, lactate, electrolytes, and bedside clinical reassessment rather than the gap alone. [18]" ], [ "Metformin user with severe persistent acidemia and hyperlactatemia", "Metformin accumulation and reduced clearance may be contributing, particularly with AKI or hypovolemia. [4][8][11]", "Stop metformin, correct precipitating illness, and consider renal replacement therapy when clinically indicated. 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Part 1: Physiology ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1111/vec.12708", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com" }, { "number": 24, "title": "Medication‐Induced Hyperlactatemia and Lactic Acidosis: A ...", "detail": "accpjournals.onlinelibrary.wiley.com", "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2316", "authors": "accpjournals.onlinelibrary.wiley.com", "host": "accpjournals.onlinelibrary.wiley.com" } ], "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.", "citations": [ { "number": 1, "title": "118 Readers' Comments - The New England Journal of Medicine", "detail": "www.nejm.org", "url": "https://www.nejm.org/cms/asset/5540603a-d6d0-4c2f-8d49-6bf86034e7a0/assetFile/NEJMra1215672_discussion_1.html", "authors": "www.nejm.org", "host": "www.nejm.org", "snippet": "... bicarbonate and dialysis may clear both intoxication and the acidosis ... Metabolic acidosis needs treatment with alkali or renal replacement therapy", "score": 0.41236505 }, { "number": 2, "title": "NEJMra1309483_discussion_1", "detail": "www.nejm.org", "url": "https://www.nejm.org/cms/asset/56571a0c-3dab-49a5-8950-6d1c5dc95c1f/assetFile/NEJMra1309483_discussion_1.html", "authors": "www.nejm.org", "host": "www.nejm.org", "snippet": "This is a case of lactic acidosis induced by medications, aspirin , metformin . Enalapril and anti-inflam. medications complicate the situation by adding", "score": 0.35287103 }, { "number": 3, "title": "NEJMra1503102_discussion_1", "detail": "www.nejm.org", "url": "https://www.nejm.org/cms/asset/246826d4-6917-48cd-b00a-87422125e3e7/assetFile/NEJMra1503102_discussion_1.html", "authors": "www.nejm.org", "host": "www.nejm.org", "snippet": "Bicarbonate is not necessary because acidosis will be corrected with reduction of blood glucose and appropiate hydration. As soon as metabolic acidosis will", "score": 0.30725458 }, { "number": 4, "title": "Metformin-Associated Lactic Acidosis in Clinical Diabetes Management | Clinical Pharmacology and Therapeutics | Pharmacology and Pharmaceutical Sciences | Health sciences | Topics | Nature Index", "detail": "www.nature.com", "url": "https://www.nature.com/nature-index/topics/l4/metformin-associated-lactic-acidosis-in-clinical-diabetes-management", "authors": "www.nature.com", "host": "www.nature.com", "snippet": "Metformin is the cornerstone of first-line therapy for type 2 diabetes mellitus owing to its proven efficacy in lowering blood glucose, favourable cardiovascular profile and cost-effectiveness. In rare circumstances, accumulation of metformin can precipitate severe lactic acidosis, a life-threatenin", "score": 0.518815 }, { "number": 5, "title": "Significance of lactate clearance in septic shock patients with high bilirubin levels | Scientific Reports", "detail": "www.nature.com", "url": "https://www.nature.com/articles/s41598-021-85700-w", "authors": "www.nature.com", "host": "www.nature.com", "snippet": "trend of lower delta anion gap was observed in survivors compared to that in non-survivors in the TBIL ≥ 2 mg/dL group (P = 0.13) (Fig. 1B,C). Lactate clearance was significantly correlated with delta anion gap in the derivation cohort (all, R = 0.54, P < 0.0001; TBIL < 2 mg/dL, R = 0.56, P = 0.0001", "score": 0.3665676 }, { "number": 6, "title": "Lactic Acidosis in Acute Severe Asthma | Respiratory Diseases | Cardiovascular Medicine and Haematology | Health sciences | Topics | Nature Index", "detail": "www.nature.com", "url": "https://www.nature.com/nature-index/topics/l4/lactic-acidosis-in-acute-severe-asthma", "authors": "www.nature.com", "host": "www.nature.com", "snippet": "### Research from Nature Portfolio\n\nNo recent Nature Portfolio content available.\n\n### Lactic Acidosis in Acute Severe Asthma publication trend\n\nThe graph below shows the total number of articles in lactic acidosis in acute severe asthma across all publications each year (not limited to Nature Index", "score": 0.34455422 }, { "number": 7, "title": "Exercise-induced lactic acidemia associated with a SLC16A13 biallelic variant | npj Genomic Medicine", "detail": "www.nature.com", "url": "https://www.nature.com/articles/s41525-026-00577-w", "authors": "www.nature.com", "host": "www.nature.com", "snippet": "Lactic acidosis is a metabolic condition defined by the accumulation of lactate in the bloodstream, leading to a decrease in physiological pH. Lactate is a normal byproduct of anaerobic glycolysis, a metabolic pathway that generates energy in the absence of sufficient oxygen. While often historicall", "score": 0.32762578 }, { "number": 8, "title": "Metformin-Induced Lactic Acidosis (MILA): Review of current diagnostic paradigm - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0735675718301116", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "## Cited by (9)\n\nBy this time in the presentation the patient will likely have irreversible blindness . Diabetic ketoacidosis, euglycemia diabetic ketoacidosis secondary to sodium-glucose cotransporter-2 (SGLT-2) inhibitors, alcoholic ketoacidosis, toxic alcohols, and severe lactic acidemia induced ", "score": 0.6773251 }, { "number": 9, "title": "Metformin-Associated Lactic Acidosis : Advanced Emergency Nursing Journal", "detail": "journals.lww.com", "url": "https://journals.lww.com/aenjournal/fulltext/2017/01000/metformin_associated_lactic_acidosis__an_atypical.5.aspx", "authors": "journals.lww.com", "host": "journals.lww.com", "snippet": "Title: Metformin-Associated Lactic Acidosis : Advanced Emergency Nursing Journal\n# Metformin-Associated Lactic Acidosis. Many Type 2 diabetic patients take metformin for its safety profile and lack of hypoglycemia. Although this drug is safe in those without renal dysfunction, lactic acidosis may ra", "score": 0.64236575 }, { "number": 10, "title": "Metformin lactic acidosis: Should we still be afraid? - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0168822719312914", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "### BMC Pharmacol Toxicol\n\n### Lactic acidosis in metformin therapy: searching for a link with metformin in reports of 'metformin-associated lactic acidosis'\n\n### Diabetes Obes Metab\n\n### Review of Biguanide (Metformin) Toxicity\n\n### J Intensive Care Med\n\n### Metformin-associated lactic acidosis: a ", "score": 0.63750535 }, { "number": 11, "title": "Metformin-Associated Lactic Acidosis - ScienceDirect", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0002962915300999", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "In patients at risk for lactic acidosis, such as those with anaerobic metabolism (ie, sepsis, hypoxia), impaired metformin clearance (significant renal impairment), or impaired lactic acid clearance (liver failure), metformin should be avoided.72 Dose reduction is recommended if the estimated glomer", "score": 0.59372765 }, { "number": 12, "title": "Metformin-associated lactic acidosis: Bridging pharmacokinetic ...", "detail": "www.sciencedirect.com", "url": "https://www.sciencedirect.com/science/article/abs/pii/S0014299926004991", "authors": "www.sciencedirect.com", "host": "www.sciencedirect.com", "snippet": "### Am. J. Med. (1997) \n R. DeFronzo _et al._\n### Metformin-associated lactic acidosis: current perspectives on causes and risk\n\n### Metabolism (2016) \n Y. Huang _et al._\n### Helicobacter pylori infection decreases metformin tolerance in patients with type 2 diabetes mellitus\n\n### Diabetes Techn", "score": 0.57952 }, { "number": 13, "title": "Metformin-associated severe lactic acidosis combined with... : Medicine", "detail": "journals.lww.com", "url": "https://journals.lww.com/md-journal/fulltext/2023/01130/metformin_associated_severe_lactic_acidosis.16.aspx", "authors": "journals.lww.com", "host": "journals.lww.com", "snippet": "Title: Metformin-associated severe lactic acidosis combined with... : Medicine\n# Metformin-associated severe lactic acidosis combined with multi-organ insufficiency induced by infection with _Aeromonas veronii_: A case report. Metformin-associated severe lactic acidosis combined with multi-organ ins", "score": 0.5674818 }, { "number": 14, "title": "A Case of Metformin Associated Lactic Acidosis : Bangladesh Journal of Endocrinology and Metabolism", "detail": "journals.lww.com", "url": "https://journals.lww.com/bjem/fulltext/2026/01000/a_case_of_metformin_associated_lactic_acidosis.13.aspx", "authors": "journals.lww.com", "host": "journals.lww.com", "snippet": "Lactic acidosis is of two types. Type-A lactic acidosis occurs due to hypoperfusion and tissue hypoxia leading to anaerobic glycolysis as in septic, cardiogenic, or hypovolemic shock and regional (limb and mesenteric) ischemia. Type-B lactic acidosis, on the other hand, is less common not associated", "score": 0.5370662 }, { "number": 15, "title": "Metformin‐Associated Lactic Acidosis Following Acute Overdose ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1002/ccr3.71607", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "Metformin Associated Lactic Acidosis refers to arterial lactate > 5 mmol/L and blood pH < 7.35 in the context of recent metformin exposure [8].", "score": 0.44985238 }, { "number": 16, "title": "Severe Metformin‐Associated Lactic Acidosis—A Case Report", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.72197", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "In general, lactic acidosis is characterized by a pH below 7.35, blood lactate levels greater than 2.0 mmol/L, and a PaCO2 under 42 mmHg.", "score": 0.44102347 }, { "number": 17, "title": "Metformin-Associated Lactic Acidosis and Blindness : Journal of the American Society of Nephrology", "detail": "journals.lww.com", "url": "https://journals.lww.com/jasn/fulltext/2020/10001/metformin_associated_lactic_acidosis_and.1683.aspx", "authors": "journals.lww.com", "host": "journals.lww.com", "snippet": "Some publications suggest vision loss (due to effect on retinal horizontal cell function) and optic nerve ischemia are associated with metformin induced lactic acidosis (MALA) at pH <7.09. It improves after correction of acidosis. But, in our case, the vision improved even before the acidemia correc", "score": 0.36786106 }, { "number": 18, "title": "Metabolic acidosis in the critically ill: Part 2. Causes and treatment - Morris - 2008 - Anaesthesia - Wiley Online Library", "detail": "associationofanaesthetists-publications.onlinelibrary.wiley.com", "url": "https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2007.05371.x", "authors": "associationofanaesthetists-publications.onlinelibrary.wiley.com", "host": "associationofanaesthetists-publications.onlinelibrary.wiley.com", "snippet": "Erroneous interpretation of hyperchloraemia and lactic acidosis (type B) during resuscitation of septic shock. A patient is admitted in extremis with septic shock via the emergency department. Fluid loading with crystalloid (0.9% saline) and colloid is ongoing and an adrenaline infusion commenced wi", "score": 0.629889 }, { "number": 19, "title": "Laboratory Recognition and Testing in Acid-Base Disorders", "detail": "academic.oup.com", "url": "https://academic.oup.com/labmed/article-pdf/30/12/776/24957270/labmed30-0776.pdf", "authors": "academic.oup.com", "host": "academic.oup.com", "snippet": "The anion gap is 26 mmol/L—12 mmol/L above normal. The most common causes of increased anion gap are ketoacidosis and lactic acidosis. In this case, ketones", "score": 0.47767657 }, { "number": 20, "title": "A clinical approach to paediatric acidebase disorders - Ovid", "detail": "academic.oup.com", "url": "https://academic.oup.com/pmj/article-pdf/88/1037/143/50018455/postgradmedj-88-143.pdf", "authors": "academic.oup.com", "host": "academic.oup.com", "snippet": "Thus, in patients with lactic acidosis, the increase in the anion gap can be as much as 1.6e1.8 times the decrease in serum bicarbonate,", "score": 0.43367022 }, { "number": 21, "title": "Clinical Vignettes Abstracts - Society of Hospital Medicine", "detail": "shmpublications.onlinelibrary.wiley.com", "url": "https://shmpublications.onlinelibrary.wiley.com/doi/pdfdirect/10.1002/jhm.92", "authors": "shmpublications.onlinelibrary.wiley.com", "host": "shmpublications.onlinelibrary.wiley.com", "snippet": "anion gap metabolic acidosis due to the uncoupling of the oxidative phosphorylation leading to the accumulation of the organic acids, such as lactic acid.", "score": 0.3199925 }, { "number": 22, "title": "Complex Metabolic Acidosis: From Case Report to Systematic ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1155/crcc/6121567", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "A 61-year-old woman was admitted with a severe high anion gap metabolic acidosis. Initially, this was attributed to elevated serum lactate", "score": 0.25515383 }, { "number": 23, "title": "Clinical use of plasma lactate concentration. Part 1: Physiology ...", "detail": "onlinelibrary.wiley.com", "url": "https://onlinelibrary.wiley.com/doi/10.1111/vec.12708", "authors": "onlinelibrary.wiley.com", "host": "onlinelibrary.wiley.com", "snippet": "Hyperlactatemia indicates that serum, plasma, or blood lactate concentration is above the relevant reference interval. Lactic acidosis refers to", "score": 0.2519241 }, { "number": 24, "title": "Medication‐Induced Hyperlactatemia and Lactic Acidosis: A ...", "detail": "accpjournals.onlinelibrary.wiley.com", "url": "https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2316", "authors": "accpjournals.onlinelibrary.wiley.com", "host": "accpjournals.onlinelibrary.wiley.com", "snippet": "The median peak lactate level was 11 (IQR 7.2–15.4) mmol/L and ranged from 2.1 to 37.5 mmol/L. Of the patients who had data to depict", "score": 0.24751921 } ], "publishedAt": "2026-09-16T00:27:02.200198+00:00", "updatedAt": "2026-09-16T00:27:02.200198+00:00", "readingMinutes": 6, "slug": "lactic-acidosis" }