F. Al-Moussally, JJ. Tien, K. Rajagopalan, C. Boterosuarez and R. Crouse (2024). Euglycemic Ketoacidosis and Lactic Acidosis Associated With Metformin Toxicity. Cureus, 16(5), e60661. https://doi.org/10.7759/cureus.60661

PubMed 38899266

[Abstract]
In patients with diabetes, diabetic ketoacidosis (DKA) is a well-documented potential complication, usually presenting with hyperglycemia, anion gap acidosis, and positive ketones. Metformin toxicity in the setting of acute renal failure is also a well-known cause of lactic acidosis. However, metformin-induced euglycemic ketoacidosis is less well-known or studied. We report a case of metformin toxicity in the setting of acute renal failure with both lactic acidosis and ketosis and an initial confounded clinical presentation of sulphonylurea-induced hypoglycemia. A high index of suspicion for metformin-associated lactic acidosis (MALA) and metformin-associated lactic acidosis with euglycemic ketoacidosis (MALKA) should be in place in patients who are taking metformin and presenting with acute renal failure and euglycemia.