Intended for healthcare professionals

Rapid response to:

Endgames Case Report

Life threatening lactic acidosis

BMJ 2010; 340 doi: (Published 25 March 2010) Cite this as: BMJ 2010;340:c857

Rapid Response:

Elderly person with Type 2 Diabetes Mellitus on Metformin: Practical Tips

Following this interesting case report*, I am haunted by one question
whether this 83 year old with Type 2 Diabetes Mellitus on Metformin has
developed an iatrogenic disease.It can not be definitely concluded but can
be assumed that an overzealous practioner in pursuit of Quality Outcome
Framework (QOF) targets has prescribed Metformin at a higher dose (3gram per
day) instead of British National Formulary (BNF) recommended maximum dose
of 2gram per day.

This case illustrates a number of take home messages for day to day
clinical practice and this should include:

1. Aim for person centred glycated haemoglobin target

2. Treat the person holistically and not the target alone

3.Do not vigorously try to achieve target

4. Keep up to date with the recent publications related to tight glycaemic
control and its perils**

5. Follow the BNF recommendations

6. Avoid increasing Metformin beyond the recommended dose

7. Consider adding drugs from other groups including Insulin for blood
sugar control when Metformin alone is insufficient

8 Monitor renal function

9.Swap Metformin Modified Release for ordinary one to avoid or minimise
gastrointestinal side effects including diarrhoea. Patient will be
immensely grateful

I do not wish to engage in the controversy surrounding
the origin of lactic acidosis. I also do not wish to challenge the concept
of myth or reality of lactic acidosis with Metformin therapy.I will leave
these contentious issues to the experts and I have concentrated on
management particularly prevention.

*Lemyze M et al. Life threatening lactic acidosis.BMJ
2010;340:c857(27 March)

** References available on request

Competing interests:
None declared

Competing interests: No competing interests

12 April 2010
Shah M Tauzeeh
Associate Specialist Physician
Finchley Memorial Hospital Granville Road London N12 0JE