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本例为一老年糖尿病患者,因长期服用大剂量苯乙双胍(降糖灵)致乳酸酸中毒。乳酸酸中毒死亡率极高,本例伴发弥散性血管内凝血及多脏器功能衰竭,幸亏得到及时的多种有效措施抢救而存活。苯乙双胍与二甲双胍同为双胍类口服降糖药,但二者分子结构不同,苯乙双胍氨基末端连接一个苯乙基,而二甲双胍连接两个甲基,以致二者分子形态和理化特性各异,导致其分子药代动力学不同。苯乙双胍可被代谢生成有生物活性的代谢产物在体内堆积,从而增加无氧糖酵解,使乳酸生成增加,并且抑制肝脏和肌肉对乳酸的摄取,同时肾脏排出减少,而易引起乳酸酸中毒;而二甲双胍代谢生成稳定的小分子物溶于水,不再代谢,90%由肾脏排出,因此在肾功能正常时,不会在体内蓄积,相对比较安全而罕见引起乳酸酸中毒。故苯乙双胍在国外早已停用,但国内尚未明确停用,在某些地方还在使用此药。本刊发表该病例,意在提醒临床医师注意:(1)老年糖尿病患者禁用苯乙双胍,慎用二甲双胍。(2)对临床适用双胍类降糖药者选用二甲双胍,停用苯乙双胍。
This case is an elderly diabetic, due to long-term use of high doses of phenformin (hypoglycemic) induced lactic acidosis. Lactic acidosis mortality is extremely high, in this case with disseminated intravascular coagulation and multiple organ failure, thanks to timely and effective measures to save a number of survival. Metformin and metformin are biguanide oral hypoglycemic agents, but the two molecular structure is different, phenylethanidine amino terminal connected to a phenethyl, and metformin connected two methyl, resulting in both morphological and physical and chemical properties of different , Leading to different molecular pharmacokinetics. Phenylebiguanide can be metabolized to produce biologically active metabolites in the body accumulation, thereby increasing anaerobic glycolysis, increased lactate production, and inhibit the liver and muscle uptake of lactic acid, while reducing renal excretion, and easy to cause lactic acid Poisoning; and metformin metabolism stable small molecules dissolved in water, no longer metabolized, 90% from the kidneys, so when the normal renal function, will not accumulate in the body, relatively safe and rare cause lactic acidosis. Therefore, phenformin has long been discontinued in foreign countries, but the country has not yet explicitly disabled, in some places are still using the drug. This publication published the case, intended to remind clinicians Note: (1) disabled elderly patients with phenformin, metformin with caution. (2) metformin hypoglycemic agents for clinical use of metformin, discontinued phenformin.