The Poison Review

Severe metabolic acidosis secondary to coadministration creatine and metformin, a case report.  Saidi H, Mani M.  Am J Emerg Med  (2010) 28:388.e5-e6

Abstract

This case report from Tehran describes a 42-year-old body builder who developed anion-gap metabolic acidosis (pH 7.25, anion gap 22 mEq/L) after taking a combination of metformin and creatine for 3 weeks. He presented with anuria (creatinine 3.5 mg/dL) and  respiratory distress due to pulmonary edema.  The authors conclude that “creatine use was the only predisposing factor for the development of acute renal failure ” in this patient, and imply that this caused metformin-induced lactic acidosis (MALA), which contributed to the unfortunate outcome in this case.

As they say on Saturday Night Live — Really??  The authors fail to evaluate fully that inconvenient unfortunate outcome — the patient suffered a fatal cardiac arrest during dialysis.  It’s hard to attribute this solely to the metabolic acidosis which — despite the article’s title — is not severe.  There is no consideration that cardiac dysnfunction might have caused both the pulmonary edema and the moderate acidosis, and that metformin was quite likely an innocent bystander.  In addition, the evidence for creatine causing renal dysfunction is at this point anecdotal, based on scattered case reports.

Finally, the editing of the manuscript is surprisingly sloppy, with at least two typos or mistakes:

• “There are 4 principal causes for high-anion-gap acidosis that we can roll out 3 of them” (emphasis mine)

• “Lactic acidosis is characterized by a broad anion-gap metabolic acidosis, pH level greater than 7.35 . . .”  (this should of course be “less than 7.35″).

In general, a poor performance all around.