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The effect of charcoal haemoperfusion on the pharmacokinetics of diltiazem is described in a patient with severe clinical toxicity following acute overdose. The patient presented within 3 h following acute ingestion of multiple medications including sustained-release diltiazem. Routine resuscitation and supportive care were administered, but hypotension did not resolve despite intravenous fluids and infusions of calcium, adrenaline, noradrenaline and vasopressin. Multiple-doses of activated charcoal, haemodialysis and charcoal haemoperfusion were prescribed to expedite the elimination of diltiazem. The maximum diltiazem concentration (577 μg.l−1) was recorded 7 h post ingestion which was followed by an erratic and prolonged elimination phase. The maximum clearance of diltiazem due to haemoperfusion was calculated to be 19.4 and 15.1 ml.min−1 at different times, equating to removal of approximately 1.5 mg diltiazem during 4 h of haemoperfusion. Haemoperfusion did not appear to remove sufficient diltiazem to recommend its routine use in the treatment of patients with acute diltiazem overdose. [ABSTRACT FROM AUTHOR]

The author discusses Type 2 diabetes metaformin therapy related complication metaphoric associated lactic acidosis (MALA) which is characterized by malaise, reduced oral intake and is associated with significant renal insufficiency. He discusses higher metformin doses and its accumulation due to reduced renal clearance are major risk factors, cause of lactic acidosis to be MALA association with phenformin and also mentions correlation of metaformin concentration with toxicity is complicated.