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This patient has poor kidney function likely exacerbated by dehydration from a viral gastroenteritis (thus his creatinine of 3.1 mg/dL and a history of diabetic nephropathy) as well as a lactic acidosis after receiving a contrast load (CT scan with contrast). A lactic acidosis is a possible complication in patients with poor kidney function who take metformin.
Metformin is an oral hypoglycemic agent that works by decreasing gluconeogenesis in the liver. It is widely regarded as the first-line oral diabetic agent. Its most concerning side effect is the development of a lactic acidosis in patients with poor renal function. Generally, patients tolerate this medication well. However, patients with poor kidney function (such as those with severe/poorly treated hypertension, diabetic nephropathy, or someone with poor kidney function who is given a contrast load) can suffer this feared complication. Whenever a patient has worsening kidney function they should no longer take metformin given this possible complication. Management of the lactic acidosis includes stopping metformin, IV fluids, and close monitoring.
Answer 1: Acyclovir can cause a crystalline nephropathy in the setting of poor kidney function but is not commonly associated with a lactic acidosis. This complication can be prevented by keeping the patient well hydrated.
Answer 2: Atorvastatin can cause rhabdomyolysis which presents with muscle pain, hyperkalemia, hypocalcemia, and myoglobinuria. For this reason, statins are often given at night.
Answer 3: Insulin is a safe alternative to metformin in patients with poor kidney function. Insulin overdose can cause hypoglycemia which can be treated with dextrose administration.
Answer 5: Metoprolol toxicity presents with somnolence, bradycardia, hypotension, and hypoglycemia and is treated with glucagon, insulin, dextrose, calcium, epinephrine, and lipid emulsion therapy.
Metformin can cause a lactic acidosis in the setting of poor kidney function.
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