Endocrine: Using metformin in ICU

[emergiQ]

Curious about the practice pattern of others with respect to metformin in ICU.

A few starting parameters:

1) Assume patient has normal renal function, thus forego the discussion of metformin-induced lactic acidosis.

2) Patient, 60 y/o Type II DM, takes metformin at home.

3) POD 3 s/p thoracotomy. Poor glucose control necessitating insulin infusion.


My strategy is to wean the infusion until able to go to q6 insulin injections +/- SSI, and once control and stability established, re-start metformin.

Pharmacy team wants to start metformin now while infusion still on. Patient also taking stress dose steroids (takes chronic at home due to ocular issue). Just starting oral feeds today (extubated this morning).


Would you guys start the metformin now or wait?

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[adam6]

Speaking in generalities:

1. I do not use metformin in the ICU
2. Oral intake should certainly be stable prior to reinitiation of metformin. Though someone has been on it for a number of years, metformin can still cause GI issues and complicate an already-complicated picture.
3. It is good practice to find a steady insulin infusion rate (ideally prior to eating for best estimate of basal requirements), transition to SQ insulin, and then restart metformin - exactly as you suggested.
4. There is no rush to start metformin. Its benefits are long-term whereas insulin is so much better for the rapidly changing environment of the ICU and even the step-down units.
5. Additionally, if there is the possibility of iodinated contrast studies, you would need to discontinue it, anyway...

Sounds like you are taking a logical approach in your thinking and are on-the-ball.

 

[staup]

I would wait, what's the benefit of starting it in the ICU?

Pharmacists add a lot to the medical team and offer good insight commonly, but sometimes not. They are not physicians. When they have hospital authority to make you do something, i.e. choose a certain equivalent antibiotic or whatever, do it, otherwise, do what you think is right.

 

[SaoTo]

Curious about the practice pattern of others with respect to metformin in ICU.

A few starting parameters:

1) Assume patient has normal renal function, thus forego the discussion of metformin-induced lactic acidosis.

2) Patient, 60 y/o Type II DM, takes metformin at home.

3) POD 3 s/p thoracotomy. Poor glucose control necessitating insulin infusion.


My strategy is to wean the infusion until able to go to q6 insulin injections +/- SSI, and once control and stability established, re-start metformin.

Pharmacy team wants to start metformin now while infusion still on. Patient also taking stress dose steroids (takes chronic at home due to ocular issue). Just starting oral feeds today (extubated this morning).


Would you guys start the metformin now or wait?

All data shows that Metformin does not cause lactic acidosis, Phenformin does.

 

[jdh71]

Curious about the practice pattern of others with respect to metformin in ICU.

A few starting parameters:

1) Assume patient has normal renal function, thus forego the discussion of metformin-induced lactic acidosis.

2) Patient, 60 y/o Type II DM, takes metformin at home.

3) POD 3 s/p thoracotomy. Poor glucose control necessitating insulin infusion.


My strategy is to wean the infusion until able to go to q6 insulin injections +/- SSI, and once control and stability established, re-start metformin.

Pharmacy team wants to start metformin now while infusion still on. Patient also taking stress dose steroids (takes chronic at home due to ocular issue). Just starting oral feeds today (extubated this morning).


Would you guys start the metformin now or wait?

It's just a matter of style. Honestly, it's metformin, who gives a ****? I wouldn't normally start the metformin mostly because, what's the point, but it's not going to hurt anything. Sometimes you do things to simply place nice with others. I think if pharmacy was like, "wanna start the metformin?", I'd be like, "ok, why the hell not."

 

[LukeWhite]

SaoTo,

I've seen two cases of metformin-induced lactic acidosis in the past two years...one was pure metformin (deliberate overdose) and one was metformin with subsequent IV contrast.

Another one of those things that is more a theoretical risk, but it killed these two folks. As others have mentioned, I'm not sure that the short term benefits of metformin are at all compelling enough to start it in the ICU. I feel that anyone who's sick enough to be in the unit (or who was sick enough to be in the unit yesterday) is probably still sick enough that an unexpected CT+/-[random body segment] is statistically plausible, if not probable.

 

[Shah_Patel_PT]

Curious about the practice pattern of others with respect to metformin in ICU.

A few starting parameters:

1) Assume patient has normal renal function, thus forego the discussion of metformin-induced lactic acidosis.

2) Patient, 60 y/o Type II DM, takes metformin at home.

3) POD 3 s/p thoracotomy. Poor glucose control necessitating insulin infusion.


My strategy is to wean the infusion until able to go to q6 insulin injections +/- SSI, and once control and stability established, re-start metformin.

Pharmacy team wants to start metformin now while infusion still on. Patient also taking stress dose steroids (takes chronic at home due to ocular issue). Just starting oral feeds today (extubated this morning).


Would you guys start the metformin now or wait?

I usually stop all po meds (diabetic).

Just use Insulin SS/Lantus since sick pt. usually require IV contrast for imaging. Some have fluctuating renal function. Some have abnormal LFTs.

Insulin is so safe and easy to titrate.

 

[WorkaholicsAnon]

I would also stay away from metformin in the ICU, especially for someone who was literally JUST extubated and who is post-op recovering from some major fluid shifts, likely got some pre-op antibiotics that may affect renal function, may NEED abx for whatever reason, and like someone already said, could be in need of a CT scan with IV contrast at some point.

Also the usefulness of lactic acid as a marker of sepsis (if occurs) will be compromised.

If the glucose levels are that difficult to control, I would do an insulin drip to see what the patient's requirement is--every diabetic is so different. And he is on glucocorticoids which doesn't help the glucose levels. Once you get to an insulin drip rate that provides good control, then you can convert over to scheduled Lantus + Q6h short-acting, adjusting as necessary once the steroids are off and once the patient is eating a normal diet.

I mean, if the patient is completely stable, awaiting discharge home from the ICU (as sometimes happens at the VA), then that's another matter altogether. But this case does not sound like the patient is there yet.

 

[Ouloplastics]

I would stay away from oral hypoglycemic in hospitalized patients period.
I am talking evidence based medicine here. Oral hypoglycemics are not only inappropriate but harmful in inpatient setup. If you look for Pubmed and search for this you will find a few good reports on this. The risks are
1. Change in their clinical status rapidly we cause potential harm if metformin still in system.
2. Patient goes for multiple procedure and tests and are fasting for unidentifiable periods sometime; leading to hypoglycemia.
3.Multiple chances of tests with dyes involved.
So SHM( Society of Hospital medicine) has taken a initiative for inpatient glycemic controls with insulin only and has shown great report.
PM me if you want to discuss more.

 

[misstofu]

I'm a pharmacist, and I don't think it is necessary to give metformin in ICU....Based on your case!

 

[mig26x]

stay with sliding scale until PO is at baseline and then on the floor when pt is more stable start metformin or just wait until discharge and put OK to continue metformin on discharge papers. I tend to skip metformin with hospitalize patients.

 

[mdc848]

I would stay away from oral hypoglycemic in hospitalized patients period.
I am talking evidence based medicine here. Oral hypoglycemics are not only inappropriate but harmful in inpatient setup. If you look for Pubmed and search for this you will find a few good reports on this. The risks are
1. Change in their clinical status rapidly we cause potential harm if metformin still in system.
2. Patient goes for multiple procedure and tests and are fasting for unidentifiable periods sometime; leading to hypoglycemia.
3.Multiple chances of tests with dyes involved.
So SHM( Society of Hospital medicine) has taken a initiative for inpatient glycemic controls with insulin only and has shown great report.
PM me if you want to discuss more.

exactly. NO PO DIABETES meds in the hospital period. put them on insulin and adjust with SS as needed. that Society of Hospital medicine website is excellent on diabetes management in the hospital.