Metformin-Induced Hemolytic Anemia

OBJECTIVE: To report a rare side effect of metformin, an oral antidiabetic drug that is used for the treatment of type 2 diabetes mellitus. CLINICAL PRESENTATION AND INTERVENTION: A 17-year-old boy was hospitalized for receiving acute lymphoblastic leukemia treatment that was composed of vincristine, L-asparaginase, daunorubicin, and prednisone. Hyperglycemia was determined without any clinical sign and metformin was started for steroid-induced insulin resistance. On the second day of metformin treatment, the patient's hemoglobin level decreased, and a direct Coombs test was positive for immunoglobulin G but negative for complement. An indirect Coombs test was negative. The glucose-6-phosphate dehydrogenase level was within the normal range. Drug-induced hemolytic anemia was suspected and metformin was discontinued. The jaundice gradually disappeared and there was no requirement for red blood cell transfusions. CONCLUSION: This case showed that physicians should be aware of the potential side effect of metformin although it is infrequent.