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Hôpital-Camfrout, France

Lalau J.-D.,Service dEndocrinologie Nutrition
Drug Safety | Year: 2010

Lactic acidosis associated with metformin treatment is a rare but important adverse event, and unravelling the problem is critical. First, this potential event still influences treatment strategies in type 2 diabetes mellitus, particularly in the many patients at risk of kidney failure, in those presenting contraindications to metformin and in the elderly. Second, the relationship between metformin and lactic acidosis is complex, since use of the drug may be causal, co-responsible or coincidental. The present review is divided into three parts, dealing with the incidence, management and prevention of lactic acidosis occurring during metformin treatment. In terms of incidence, the objective of this article is to counter the conventional view of the link between metformin and lactic acidosis, according to which metformin-associated lactic acidosis is rare but is still associated with a high rate of mortality. In fact, the direct metformin-related mortality is close to zero and metformin may even be protective in cases of very severe lactic acidosis unrelated to the drug. Metformin has also inherited a negative class effect, since the early biguanide, phenformin, was associated with more frequent and sometimes fatal lactic acidosis. In the second part of this review, the objective is to identify the most efficient patient management methods based on our knowledge of how metformin acts on glucoselactate metabolism and how lactic acidosis may occur (at the organ and cellular levels) during metformin treatment. The liver appears to be a key organ for both the antidiabetic effect of metformin and the development of lactic acidosis; the latter is attributed to mitochondrial impairment and subsequent adenosine triphosphate depletion, acceleration of the glycolytic flux, increased glucose uptake and the generation of lactate, which effluxes into the circulation rather than being oxidized further. Haemodialysis should systematically be performed in severe forms of lactic acidosis, since it provides both symptomatic and aetiological treatment (by eliminating lactate and metformin). In the third part of the review (prevention), the objective is to examine the list of contraindications to metformin (primarily related to renal and cardiovascular function). Diabetes is above all a vascular disease and metformin is a vascular drug with antidiabetic properties. Given the importance of the liver in lactate clearance, we suggest focusing on the severity of and prognosis for liver disease; renal dysfunction is only a prerequisite for metformin accumulation, which may only be dangerous per se when associated with liver failure. Lastly, in view of metformins impressive overall effectiveness profile, it would be paradoxical to deny the majority of patients with long-established diabetes access to metformin because of the high prevalence of contraindications. The implications of these contraindications are discussed. © 2010 Adis Data Information BV. All rights reserved.

Lalau J.-D.,Service dEndocrinologie Nutrition
Medecine des Maladies Metaboliques | Year: 2015

The author details here how the issue of nutrient transformation has been addressed throughout history. This is not only from a historiographical but also from a clinical point of view. © 2015 Elsevier Masson SAS- Tous droits réservés.

Lalau J.-D.,Service dEndocrinologie Nutrition
Medecine des Maladies Metaboliques | Year: 2014

Healthcare must be delivered with care. But ethics themselves must be cared for. Indeed there is a great risk that ethics will become utilitarian. Ethics are not tools for our benefit; on the contrary, they are our masters! © 2014 - Elsevier Masson SAS - Tous droits réservés.

The response of the psychiatrist to a demand of " psy advice" varies according to its theoretical orientation. An ethical structure corresponds to each practice. On the contrary, if this response becomes the condition of a possible statement of the complaint, then it is possible to define the ethics of psychiatry as this kind of obligation where I answer 'in front of' the other. Inspired by the work of Levinas, this ethics of this response defines the ethics of psychiatry. © 2010.

Lalau J.-D.,Service dEndocrinologie Nutrition
Medecine des Maladies Metaboliques | Year: 2011

The word "observance" [the French term for "compliance" , in the sense "treatment compliance"] unquestionably means many different things. First and foremost, "observing" involves examining something closely, i.e. using one's eyes - a part of the body, which throws up a host of new (and not-so-new) issues whenever science (which is supposedly objective) calls one's own objectivity into question. According to Gaston Bachelard, "observing" means overcoming the various epistemological barriers to scientific understanding [1]. So let us observe the complications of compliance⋯.© 2011 - Elsevier Masson SAS - Tous droits réservés.

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