# Severe Metabolic Acidosis Related to Simultaneous Use of Metformin and Dapagliflozin: A Case Report

## TL;DR

An elderly woman with diabetes developed severe acidosis after using metformin and dapagliflozin together, highlighting the risks of combining these drugs.

## Contribution

This case report highlights the life-threatening risk of combining metformin and SGLT2 inhibitors during volume depletion.

## Key findings

- Severe acidosis occurred in a patient on metformin and dapagliflozin with dehydration.
- Acute kidney injury and elevated lactic acid and ketones were observed.
- Acidosis resolved after ICU care, renal replacement therapy, and vasopressor support.

## Abstract

We report the case of a 73-year-old woman with type 2 diabetes mellitus (T2D) who developed severe high anion gap metabolic acidosis while on chronic metformin and dapagliflozin therapy. She presented with dehydration following gastrointestinal symptoms, and venous blood gas revealed profound acidosis. Laboratory evaluation showed acute kidney injury and elevated metformin, lactic acid, and ketone blood levels. Despite initial supportive care, she required ICU admission, renal replacement therapy, and vasopressor support. Acidosis resolved within 36 hours. This case highlights the potentially life-threatening risk of combined metformin and sodium-glucose cotransporter 2 (SGLT2) inhibitor use in the setting of volume depletion. Clinicians should monitor renal function and hydration status carefully when prescribing this combination, particularly in elderly patients or those on diuretics.