In this episode, Drs. Pradip Kamat, Monica Gray, and Rahul Damania talk through a heartbreaking case involving a 14-year-old girl with a history of psychiatric illness who intentionally took 45 tablets of metformin and empagliflozin. Things went downhill quickly—she developed severe lactic acidosis, hypoglycemia, acute kidney injury, and eventually suffered a cardiac arrest that required ECMO and continuous dialysis. Sadly, even with the most aggressive care, she didn’t make it. The doctors walk listeners through the pharmacology and toxicity of metformin and empagliflozin, discuss how these drugs can cause harm, and share key management strategies. They really stress the importance of early recognition, using extracorporeal therapies, and working as a multidisciplinary team when dealing with severe pediatric overdoses of antidiabetic medications.

Show Highlights:

Case study of a 14-year-old girl with intentional ingestion of an oral antidiabetic agent
Presentation of severe lactic acidosis, hypoglycemia, acute kidney injury, and cardiac arrest
Discussion of the pharmacology and toxicology of metformin and empagliflozin
Mechanisms of metformin toxicity and its effects on metabolic processes
Differentiation between types of lactic acidosis related to metformin
Importance of early recognition and management of metformin toxicity
Supportive care strategies for managing severe metformin overdose
Role of extracorporeal therapies, including ECMO and dialysis, in treatment
Multidisciplinary approach involving intensivists, nephrologists, and toxicologists
Clinical implications and outcomes of severe metformin toxicity in pediatric patients

Resources:

Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Nothing found
Reference 1: Noites I, Figueiredo M, Shchomak Z, Boto L, Camilo C. Fatal Pediatric Metformin-Associated Lactic Acidosis: When Severity Goes Unnoticed. Cureus. 2026 Feb 16;18(2):e103719.
Reference 2: Bebarta VS, Pead J, Varney SM. Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care. 2015 Aug;31(8):589-90.

Metformin Overdose in the Pediatric ICU | A Case of Low pH

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Metformin Overdose in the Pediatric ICU | A Case of Low pH