Tuesday, October 21, 2014

Tuesday, October 20, 2009 Dr G, Community Member, asks

Q: Metformin and radiocontrast dye

Why should we stop using metformin before a radiocontrast image? And what are the proofs that lactic acidosis or other complications may be exacerbated by this action? If we have to stop it, is it for every diabetic patient before imaging? Thank you

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Answers (4)
CharlieD, Community Member
11/ 6/09 11:17am

The reason we stop metformin is because there is an increased risk of lactic acidosis. The reason for this is that radiocontrast dyes are shown to cause acute renal failure. Since metformin is cleared virtually exclussivley by renal mechanisms, this may cause increased concentrations of metformin, leading to lactic acidosis. The fact that the patient is a diabetic is irrelevant to whether you d/c the drug or not. If they take metformin, whether it be for diabetes, weightloss or anything else, you stop metformin 48 hours before and wait 48 hours after radiocontrast before reinitiaing metformin therapy. Hope this helps!

Dr G, Community Member
11/ 6/09 4:46pm

Thx for replying! I was thinking with the same logic but the fact is that I haven't seen in any reference that radiocontrast agents can "CAUSE" acute renal failure, they are however contraindicated (or used with pecaution) in cases of renal failure that is already present, because their clearance is retarded. But whether they can cause the renal failure am not sure about it. If it was the case, all treatments that are eliminated by kidneys (which are many) must be stopped before every radiocontrast imaging to prevent intoxication, and not only Metformin. Thanks again for ur reply, it makes a good medical discussion!

RN who does her homework, Community Member
12/ 1/09 12:19pm

Dr. G:  "what are the proofs that lactic acidosis ... may be exacerbated by this action  (using metformin concurrently with radiocontrast image)?"   I don't know the specific studies it was based on but it is common enough that there is now a black box warning on metformin about this; and LAST WEEK, in the hospital where I work, they killed a patient in exactly this way.  He was on metformin, nobody discontinued it, he had a CT scan with contrast, and within 3 days he developed increasing lactic acidosis and died of it.  I have been researching this and apparently this is the general chain of events:  dyes impair kidney function, at best temporarily but I have seen several patients whose kidneys were permanently damaged by contrast medium. The patient is supposed to be instructed to drink copious amounts of water before and after the procedure to dilute the concentration of dye as it passes through - but often this critical step is neglected.  Lactic acidosis develops when lactate, a product of carbohydrate metabolism, accumulates faster than the liver can metabolize it.  Metformin is eliminated through the kidneys.  When this filtration is impaired the blood levels of it increase greatly.  Too much carbohydrate metabolism goes on and the lactate builds up, the blood pH goes down, you have acidosis. 

Student Radiographer, Community Member
1/18/11 8:20am

I suggest you google nephrogenic systemic fibrosis and look at journals there are loads re. RCA's causing loss of kidney function, some suggest 48 hours of increased fluids before and after, the theory hydrating the kidneys may minimise the damage. Undecided

madge, Community Member
7/14/12 1:27pm

can metformin be taken before/after a petscan - if not why - if taken how long before /after petscan

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By Dr G, Community Member— Last Modified: 09/11/13, First Published: 10/20/09