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There have been post-marketing cases of metformin-associated lactic acidosisincluding fatal casesThese cases had a subtle onset and were accompanied by nonspecific symptoms such as malaisemyalgiasabdominal painrespiratory distressor increased somnolencehoweverhypotension and resistant bradyarrhythmias have occurred with severe acidosisMetformin-associated lactic acidosis was characterized by elevated blood lactate concentrations5 mmol/Lanion gap acidosiswithout evidence of ketonuria or ketonemiaand an increases lactate:pyruvate ratiometformin plasma levels were generally5 mcg/mLMetformin decreases liver uptake of lactate increasing lactate blood levels which may increase the risk of lactic acidosisespecially in patients at risk.

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