Metformin management

MANAGING LACTIC ACIDOSIS. When taking metformin, the patient is at risk for lactic acidosis. The nurse monitors die patient for symptoms of lactic acidosis, which include unexplained hyperventilation, myalgia, malaise, gastrointestinal symptoms, or unusual somnolence If the patient experiences these symptoms, the nurse should contact the primary care provider at once. Elevated blood lactate levels of greater than 5 mmol/L are associated with lactic acidosis and should be reported immediately. Once a patient s diabetes is stabilized on metformin therapy, the adverse GI reactions that often occur at the beginning of such therapy are unlikely to be related to the drug therapy. A later occurrence of GI symptoms is more likely to be related to lactic acidosis or other serious disease. 

Patient management Monitor long-term efficacy by measurement of HbA- c levels approximately every 3 months. When hypoglycemia occurs in patients taking a combination of repaglinide and a thiazolidinedione or repaglinide and metformin, reduce the dose of repaglinide. 

Lactic acidosis is a medical emergency that must be treated in a hospital setting. In a patient with lactic acidosis who is taking metformin, immediately discontinue the drug and promptly institute general supportive measures. Because metformin is dialyzable (with a clearance of up to 170 mL/min under good hemodynamic conditions), prompt hemodialysis is recommended to correct the acidosis and remove the accumulated metformin. Such management often results in prompt reversal of symptoms and recovery. 

Post-study monitoring showed that 5 years after the closure of the UKPDS, the benefits of intensive management on diabetic endpoints was maintained and the risk reduction for a myocardial infarction became significant. The benefits of metformin therapy were maintained. 

DeWitt DE, Evans TC. Perioperative management of oral antihyperglycemic agents special consideration for metformin. Semin Anesth 1998 17 267-72. 

McNulty, S. J., E. Ur and G. Williams (2003). A randomized trial of sibutramine in the management of obese type 2 diabetic patients treated with metformin. Diabetes Care 26(1) 125-31. 

Coetzee EJ, Jackson WPU. Metformin in management of pregnant insulin dependent diabetics. Diabetologia 1979 16 241-245. 

Teale KFH et al The management of metformin overdose. Anaesthesia 1998 53 698-701. [PMID 9771180] (Three case reports with severe lactic acidosis and cardiovascular collapse,... 

There is some evidence that a small increase in the dosage of phenprocoumon may be necessary if metformin is given but it seems likely that this can be managed with routine anticoagulant monitoring. ... 

Berne C the Oriistat Swedish Type 2 diabetes Study Group. A randomized study of oriistat in combination with a weight management programme in obese patients with type 2 diabetes treated with metformin Diabet Med (2005) 22, 612-18. 

This patient had also taken hypotensive agents, which may have made management more complicated. Metformin concentrations have not been found to correlate with mortality. 

Cefalu WT, Buse JB, Del Prato S et al (2014) Beyond metformin safety considerations in the decision-making process for selecting a second medication for type 2 diabetes management reflections from a diabetes care editors expert forum. Diabetes Care 37 2647-2659 Cemea S, Cahn A, Raz 1 (2016) SaxagUptm for the treatment of diabetes a focus on stifety. Expert Opin Drug Saf 15 696-707... 

Responsibilities for management of chronic and preoperative medication need to be clearly defined and communicated between all involved caregivers. Timely prescription (e.g. treatment of preoperative anemia), reliable continuation (e.g. beta-blockers, aspirin, statins) [2], timely discontinuation (e.g. metformin, platelet inhibitors, new oral anticoagulants), and effective bridging (insulin, unfractionated heparin) of preoperative medications increase patient safety by reducing risks of myocardial ischemia, bleeding and transfusion, and help to avoid case cancellations. 

A systematic review of nine randomised clinical trials of adequate methodological quality addressed the efficacy and safety of metformin combined with lifestyle interventions in the management of adolescent obesity. The results indicate that among obese adolescents with no associated diseases, the administration of metformin is relatively effective in the short term for reducing BMI. Long-term drug s effects were unknown [22 ]. 

Game MA, Khmana ML, Nisar S, Shah PA, Shah ZA, KuJshrestha B, et al. Improved efficacy of low-dose spironolactone and metformin combination than either drug alone in the management of women with polycystic ovary syndrome (PCOS) a six-month, open-label randomized study. J Chn Endocrinol Metab 2013 98(9) 3599-607. 

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