Multiple drugs
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Multiple drugs Lactic acidosis and acute kidney injury: case report
A man in his early 20s developed lactic acidosis following metformin and levothyroxine sodium overdoses. He also developed acute kidney injury (AKI) while receiving telmisartan/hydrochlorothiazide and metformin overdose [not all routes stated]. The man, who had type 2 diabetes mellitus, hypertension and hypothyroidism, presented with agitation, severe abdominal pain and vomiting to the emergency department an hour following an ingestion of mixed overdose of 50-60g of metformin and an unclear amount of levothyroxine sodium [dosage not stated]. He was also on regular medications including metformin 500mg daily, levothyroxine sodium 225µg daily, amlodipine and telmisartan/hydrochlorothiazide 20mg/6.25mg pill daily [indications not stated]. On presentation, his BP was 86/41 mmHg. Blood biochemistry revealed AKI. Venous blood gas revealed a compensated metabolic acidosis. The man was treated with fluid resuscitation with crystalloids and admitted to the acute medical unit. His BP improved, but on repeat blood biochemistry revealed worsening of lactic acidosis and renal function. After 10 hour of presentation, he was shifted to ICU where he was incubated, ventilated and central venous access secured. At this time, his pH and lactate were 6.89 and 28 mmol/L, respectively. He was started on continuous venovenous haemofiltration (CVVH) and IV infusion of bicarbonate. His BP was managed by norepinephrine 0.1 µg/kg/min. Due to persistently raised lactate level, he switched to continuous venovenous haemodialysis (CVVHD) with 6000 mL/hour pending commencement on imtermittent haemodialysis (IHD). He was also given vitamin K and acetylcysteine. CVVHD and IHD was discontinued after 34 hours; pH was 7.51 and lactate and clotting normalised. Renal function significantly improved. His recovery was complicated by ventilator-associated pneumonia. He remained well after the admission. Goonoo MS, et al. Metformin-associated lactic acidosis: Reinforcing learning points. BMJ Case Reports 13: e235608, No. 9, 2 Sep 2020. Available from: URL: http:// 803506165 doi.org/10.1136/bcr-2020-235608
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Editorial comment: Details of this case report have previously been published and processed for Adis PV [see Reactions 1646 p213; 803235737 ].
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Reactions 10 Oct 2020 No. 1825
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