Two Rare Cases of Fatal Intoxication From Metformin and Literature Review
Bibliographic record
Abstract
Metformin is an antihyperglycemic agent that is mostly used for treatment of hyperglycemia in type 2 diabetes. Metformin is available in the form of 500- and 850-mg tablets. The recommended therapeutic dose in adults is 500 to 2,500 mg/d. It decreases hepatic glucose production and lowers glucose absorption from the gastrointestinal tract. Fatal intoxication with metformin is rare. We report our experience with 2 rare cases in which patients were found unresponsive following intoxication with metformin with a high serum concentration. Case 1: An 84-year-old woman who had a recent history of flu symptoms was found unresponsive on the floor of her bedroom. Her medical history included diabetes and osteoporosis. At autopsy, severe coronary and systemic atherosclerosis and sigmoid diverticulosis were identified. Blood toxicology analysis showed a high concentration metformin of 103 mg/L. Case 2: A 29-year-old woman was found unresponsive in her room with an empty metformin bottle. She was admitted to the emergency department, but resuscitation was unsuccessful. Her medical hsitory included depression, anxiety, and substance misuse. At autopsy, no evidence of significant pathologic disease was identified. Blood toxicology analysis showed a high concentration metformin of 57.6 mg/L. In both cases, severe lactic acidosis was detected. A MEDLINE search showed that deaths following metformin overdose are rare. Plasma concentration of metformin in this population was in a range from 55 to 200 mg/L. Drowsiness and coma were usually the final clinical presentation (100%). Concomitant multiple drugs or underlying hepato-renal dysfunction was almost always present. Severe lactic acidosis was present in almost all reported cases (100%). Autopsy findings were nonspecific. Fatal metformin overdose is rare. Diarrhea and vomiting are the earliest symptoms of metformin intoxication followed by tachycardia, drowsiness, and coma. Metformin should not be used in patients at high risk of lactic acidosis. These rare cases show that an advanced forensic toxicologic overview is needed in forensic pathology practice.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.008 | 0.006 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.002 | 0.003 |
| Open science | 0.002 | 0.002 |
| Research integrity | 0.004 | 0.002 |
| Insufficient payload (model declined to judge) | 0.004 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".