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Lactic acidosis
This is a rare but very serious and life-threatening metabolic crisis that is said to occur more frequently in people with diabetes. There are two types (type A-anaerobic and type B-aerobic) and their causes are listed in Table 12.5.
Whereas there is good evidence for a causative role of the biguanide phenformin, there is considerable debate as to whether metformin use per se is associated with lactic acidosis. A Cochrane systematic review of all reported trials found no episodes in 59,321 patient-years of metformin therapy or in 51,627 patient-years in diabetic patients not on metformin. Most reported cases in people with diabetes (on metformin or not) are in those with one of the serious underlying conditions listed in the table.
Most patients present with a profound metabolic acidosis with a massive anion gap. Treatment is of the underlying condition (which often determines outcome) and large volumes of IV bicarbonate are often required. Dichloroacetate can also be used to block lactate production but its use is confined to specialist centres. Most patients require ITU monitoring and care.
Further Reading:
Angus VC , Waugh N. Hospital admission patterns subsequent to diagnosis of type 1 diabetes in children: a systematic review. BMC Health Serv Res 2007; 7:199. Available from: www.biomedcentral.com/1472-6963/7/199.
Joint British Diabetes Societies Inpatient Care Group . The management of diabetic ketoacidosis in adults. Available at: www.diabetes.nhs.uk.
English P, Williams G. Hyperglycaemic crises and lactic acidosis in diabetes mellitus. Postgrad Med J 2004; 80:253 – 261.
Kitabchi AE, Miles JM, Umpierrez GE, Fisher JW. Hyperglycaemic crises in adult patients with diabetes. Diabetes Care 2009; 32:1335 – 1343.
Umpierrez GE, Smiley D, Kitabchi AE. Narrative review: ketosis prone type 2 diabetes mellitus: Ann Intern Med 2006; 144:350 – 357.
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