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

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 agentPresentation of severe lactic acidosis, hypoglycemia, acute kidney injury, and cardiac arrestDiscussion of the pharmacology and toxicology of metformin and empagliflozinMechanisms of metformin toxicity and its effects on metabolic processesDifferentiation between types of lactic acidosis related to metforminImportance of early recognition and management of metformin toxicitySupportive care strategies for managing severe metformin overdoseRole of extracorporeal therapies, including ECMO and dialysis, in treatmentMultidisciplinary approach involving intensivists, nephrologists, and toxicologistsClinical implications and outcomes of severe metformin toxicity in pediatric patientsResources:Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Nothing foundReference 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.