Symptomatic Hypoglycemia During Treatment with a Therapeutic Dose of Metformin

Abstract

Patient: Male, 58-year-old Final Diagnosis: Diabetes mellitus type 2 Symptoms: Confusion • diaphoresis • dizziness • dyspnea • palpitation • weakness Medication: Metformin Clinical Procedure: — Specialty: Endocrinology and Metabolic • General and Internal Medicine • Psychiatry Objective: Unusual clinical course Background: Metformin has a longstanding reputation as the first-line treatment for glycemic control in the setting of diabetes mellitus type 2. A contributing factor to this reputation is metformin having a low risk of inducing hypoglycemia compared to other oral hypoglycemics or insulin. There are no case reports of hypoglycemia while on conventional or therapeutic doses of metformin. This case report is of a patient who developed symptomatic hypoglycemia while being treated with a therapeutic dose of metformin. Case Report: A 58-year-old man with history including diabetes mellitus type 2, hypertension, and schizoaffective disorder was dismissed early from work due to symptoms of severe weakness, confusion, diaphoresis, dizziness, shortness of breath, palpitations, and a sensation of feeling hot. Continuous glucose monitoring revealed hypoglycemic episodes up to 4% of the time. The hypoglycemic events appeared to occur primarily between midnight and 7 A.M., with the second likely time frame being between 7A.M. and noon. Within 2 weeks of discontinuing metformin, there were no further “attacks”, and the chronic daytime fatigue and somnolence significantly improved. Conclusions: This case report suggests that there is a risk of symptomatic hypoglycemia with therapeutic doses of metformin. Although advised to be taken with meals to avoid gastrointestinal upset, patients should also be educated to take metformin with meals to reduce the risk of metformin-associated hypoglycemia.

Observational assessments of the relationship of dietary and pharmacological treatment on continuous measures of dysglycemia over 24 hours in women with gestational diabetes

“…Noteworthy, metformin is only prescribed when women are failing to achieve glucose targets with diet alone; therefore, glucose levels in this group are higher. Estimates from recent trials suggest that at higher doses metformin can reduce HbA1c by 1-2% (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22) mmol/mol) (43), this is promising as it has been reported that a 1 % reduction in HbA1c in women with GDM is associated with improved maternal and offspring outcomes (44).…”

“…However, where management of dysglycemia is more difficult, pharmacological therapy may be needed. Metformin, an oral antihyperglycemic drug, has been used as a secondary line treatment for glycemic control in T2DM for decades (21, 22). In women with GDM, the UK clinical guidelines also recommend metformin as secondary-line treatment in the management of dysglycemia (3), with added benefits linked to reduced gestational weight gain, maternal hypertensive disorders, macrosomia, neonatal hypoglycemia, and intensive care unit admissions (3).…”

Review Farmakoterapi Diabetes Melitus

“…Berdasarkan penelitian yang dilakukan oleh Joseph et al (2021), tidak terdapat laporan kasus hipoglikemia pada saat menggunakan terapi metformin. Risiko terjadinya hipoglikemia jarang terjadi, namun bukan berarti tidak terjadi, pasien tetap harus disarankan penggunaan metformin bersamaan dengan makanan, agar meminimalkan efek samping pada gastroinstentinal serta meminimalkan risiko hipoglikemia (Joseph, 2021).…”

“…Berdasarkan penelitian yang dilakukan oleh Joseph et al (2021), tidak terdapat laporan kasus hipoglikemia pada saat menggunakan terapi metformin. Risiko terjadinya hipoglikemia jarang terjadi, namun bukan berarti tidak terjadi, pasien tetap harus disarankan penggunaan metformin bersamaan dengan makanan, agar meminimalkan efek samping pada gastroinstentinal serta meminimalkan risiko hipoglikemia (Joseph, 2021). Efek yang kuat dari metformin dalam penurunan glukosa adalah kompleks dan kemungkingan dicapai melalui pengobatan multifaktor farmasi bersamaan dengan gaya hidup yang keduanya merupakan faktor penting dalam terapi diabetes tipe 2.…”

Observational assessments of the relationship of dietary and pharmacological treatment on continuous measures of dysglycemia over 24 hours in women with gestational diabetes

“…However, where management of dysglycemia is more difficult, pharmacological therapy may be needed. Metformin, an oral antihyperglycemic drug, has been used as a secondary line therapy for glycemic control in T2DM for decades ( 21 , 22 ). In women with GDM, the UK clinical guidelines also recommend metformin as secondary-line therapy in the management of dysglycemia ( 3 ), with added benefits linked to reduced gestational weight gain, maternal hypertensive disorders, macrosomia, neonatal hypoglycemia, and intensive care unit admissions ( 3 ).…”