Management of Metformin in Lactic Acidosis

Clinical Context and Risk Factors

Acute conditions predisposing to lactic acidosis, such as cardiogenic or distributive shock, sepsis, hypoxia, acute kidney injury, and dehydration, require discontinuation of metformin 1, 2
In hospitalized patients at risk for lactic acidosis, metformin should be avoided due to impaired metformin clearance from renal impairment or impaired lactate clearance from liver failure 1
Metformin use in COVID-19 patients is associated with increased lactic acidosis incidence, particularly with higher doses, worse kidney function, and greater disease severity 1

Hemodynamic stability should be confirmed without vasopressor support before restarting metformin, as recommended by the guideline society 3
Renal function should be stable with at least two consistent measurements showing eGFR ≥30 mL/min/1.73m² before restarting metformin, according to the guideline society 3, 4