ODP224 Metformin Associated Lactic Acidosis in a Nondiabetic Young Female

BACKGROUND: Metformin is the first line of treatment for patients with Diabetes Mellitus type 2. Despite multiple benefits, metformin is contraindicated in stage 4 renal disease due to an increased risk of metformin associated lactic acidosis (MALA). MALA is estimated to have a high mortality rate of 30-50%. The presentation of MALA can mimic sepsis and organ failure. CLINICAL CASE: We report a case of a 32 year old female who presented with generalized weakness and shortness of breath. She was found to have severe metabolic acidosis (PH 7. 04, PCO2 40 mmHg, Bicarb 15 mmol/L, anion gap 14 mmol/L, lactic acid 8.7 mmol/L), hypotension (82/46 mmHg), pancytopenia, moderate transaminitis, severe acute kidney injury (creatinine 3.2 mg/dL, GFR 17 mL/min/1.73 m2), and profound hypoglycemia (serum glucose 42 mg/dL). Endocrinology was consulted due to hypoglycemia and suspected adrenal insufficiency. During the encounter the patient was alert and oriented, but reported severe nausea and appeared in significant distress. On review of medications, she reported taking phentermine and metformin for weight loss, hydrochlorothiazide for hypertension, and fluoxetine for depression. She denied taking other supplements. She denied any history of diabetes mellitus or prediabetes. Computed tomography (CT) of the chest and abdomen were unremarkable. The patient's potassium was normal. Lactic acidosis continued to increase (16.1 mmol/L) despite intravenous fluids, empiric broad spectrum antibiotics, and stress dose steroids. Approximately 19 hours after the arrival, she underwent dialysis due to suspected MALA. Her lactic acid improved after dialysis transiently (6.1 mmol/L), but later worsened again (11.3 mmol/L). Urine and blood cultures returned positive for Klebsiella Pneumoniae (pan-sensitive). She was treated appropriately for sepsis since presentation to the emergency room, but her clinical condition (and lactic acid) continued to deteriorate. On the second day of admission, the patient developed respiratory failure requiring intubation and mechanical ventilation. Her hypotension persisted and she required multiple pressors. Sustained low-efficiency dialysis was restarted due to worsening of metabolic acidosis. Patient then became unresponsive on hospital day 4. Sedation was stopped and CT of the brain revealed significant edema and mild bilateral subarachnoid hemorrhage. Patient was confirmed brain dead by perfusion study. CONCLUSION: This case illustrated a constellation of factors that led to a poor outcome. Off label use of metformin for weight loss, late diagnosis of acute severe renal failure, and delayed diagnosis of MALA all contributed to the poor outcome in this patient. Even though MALA has a relatively low estimated incidence rate, this case emphasizes the importance of medication reconciliation and the need for recognition that MALA can present as sepsis. Presentation: No date and time listed