Metformin
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Megaloblastic anaemia: case report A 62-year-old patient [sex not stated] developed megaloblastic anaemia during treatment with metformin for type 2 diabetes mellitus. The patient presented at an emergency room in October 2019 with fatigability, headache, dizziness, dyspnoea during moderate effort, palpitations, nausea, bloating, epigastric pain and pain in the right hypochondrium. The patient was hospitalised. It was found that the patient had been diagnosed with type 2 diabetes mellitus in 2015. In 2015, the patient had started receiving oral metformin 1g twice a day. In 2018, sitagliptin had been added to the therapeutic plan. The other concomitant medications included bisoprolol, perindopril and indapamide. The patients’ history did not reveal alcohol abuse or smoking. Physical examination revealed the following: obesity grade II (BMI=37 kg/m2), an abdominal circumference of 116cm, skin paleness, slight dehydration, rhythmic heartbeat, a BP of 105/70mm Hg, a pulse rate of 92 beats/min, no pathological heart murmurs and a glycaemia equal to 220 mg/dL. Blood tests revealed an unsatisfactory glycaemic control; however, the patient’s renal and hepatic functions were normal. Further investigations revealed decreased levels of haemoglobin, haematocrit, erythrocytes and thrombocytes, as well as, increased levels of mean erythrocyte volume, mean erythrocyte haemoglobin and mean erythrocyte haemoglobin concentration. Iron and leukocyte levels were found to be normal. A diagnosis of megaloblastic anaemia was made as per the WHO criteria. In view of the haematologic panel, a peripheral blood smear was performed which showed anisocytosis with hypochromic erythrocytes, macrocytes, codocytes, isolated thrombocytes as well as thrombocytes in small or medium groups. Due to the poor glycaemic control, high glycaemic values and clinical symptoms, metformin and sitagliptin were stopped, and insulin therapy was initiated. After the treatment modification, the patients’ symptoms significantly improved. Dyspnoea and gastric discomfort disappeared. An EKG, chest X-ray, abdominal echography and gastroscopy were performed. These investigations did not reveal any notable pathological changes, significant to other conditions. Vitamin B12 and folate were measured. Results showed that the concentration of vitamin B12 was very low, confirming vitamin B12 deficiency. However, the serum concentration of folate was in the normal range. Substitution treatment with vitamin B12 was initiated. For obtaining a good glycaemic control, the patient received insulin glargine [glargine] and sitagliptin was resumed. Three months later, the patient was re-admitted for further evaluation; it was found that patient’s megaloblastic anaemia had resolved, the glycaemic control was remarkably improved and the vitamin B12 was in the normal range. Albai O, et al. Metformin treatment: A potential cause of megaloblastic anemia in patients with type 2 diabetes mellitus. Diabetes, Metabolic Syndrome and Obesity: Targets 803518575 and Therapy 13: 3873-3878, 2020.
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