Metformin-Associated Lactic Acidosis and Relative Euglycemic Ketoacidosis Precipitated by a Glucagon-Like Peptide-1 Receptor Agonist: A Case Report and Literature Review.

A single case plus a small literature review, but the safety lesson is concrete: the nausea, vomiting, and reduced intake common on incretin drugs can set up dehydration and kidney injury that lets metformin accumulate, while a deceptively normal glucose masks the ketoacidosis. This is a rare combination — MALA itself occurs in fewer than 10 per 100,000 patient-years — so the finding warrants awareness, not alarm. The clinical takeaway is early ketone measurement in sick patients on this drug combination.