Metformin, a commonly prescribed medication for type 2 diabetes, is taken daily by millions of Americans. Given its regular use, it's natural to have questions about how it interacts with daily life, including alcohol consumption. While moderate alcohol intake may be acceptable for some individuals on metformin, it's crucial to understand the potential risks and interactions between alcohol and this medication.
Can You Drink Alcohol While Taking Metformin?
Generally, moderate alcohol consumption may be acceptable while taking metformin, especially if your diabetes is well-controlled and your healthcare provider gives the go-ahead. Moderate drinking is typically defined as up to one drink per day for women and no more than two drinks per day for men.
A standard drink is equivalent to:
- 12 oz of beer
- 8 oz of malt liquor
- 5 oz of wine
- 1.5 oz of distilled spirits (vodka, whiskey, etc.)
However, heavy or binge drinking while on metformin can be dangerous. Heavy drinking is defined as eight or more drinks per week for women and fifteen or more drinks per week for men. Binge drinking is consuming four or more drinks on a single occasion for women and five or more drinks on a single occasion for men.
If you have type 2 diabetes and plan to drink alcohol while taking metformin, consider these tips:
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- Avoid drinking on an empty stomach.
- Drink water before and after alcohol consumption to prevent dehydration.
- Avoid heavy or binge drinking, sticking to recommended serving sizes.
- Avoid sugary mixers and cocktails when possible.
- Monitor your blood sugar levels before drinking, before bed, and for up to 24 hours after drinking.
It's essential to consult your doctor before drinking alcohol while taking metformin, even if your blood sugar levels are stable. Your healthcare provider can provide personalized guidance based on your medical history and specific health needs.
Who is at Higher Risk?
While moderate drinking may be safe for some, certain individuals face a greater risk of health complications when combining alcohol with metformin. These groups include:
- People with liver or kidney problems: Alcohol and metformin can place additional stress on these organs, increasing the risk of serious health issues.
- People taking insulin or other diabetes medications: Alcohol can cause blood sugar to drop too low (hypoglycemia) when combined with these drugs.
- Women: Alcohol often affects women more intensely than men, potentially increasing the chance of side effects.
- Older adults: The body processes alcohol differently with age, raising the risk of low blood sugar or dizziness.
If you fall into any of these categories, consulting your doctor before drinking alcohol while on metformin is particularly important.
How Metformin Works
Metformin helps maintain healthy blood sugar (glucose) levels in the body. This is crucial for individuals with type 2 diabetes, prediabetes, and polycystic ovary syndrome (PCOS), where blood sugar levels are often elevated.
In these conditions, the body may develop insulin resistance, where cells don't respond effectively to insulin, a hormone that helps move sugar from the blood into cells. As a result, sugar accumulates in the blood instead of being used for energy.
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Metformin helps lower blood sugar levels in two primary ways:
- Reducing Liver Sugar Production: It signals the liver to slow down its production of sugar.
- Increasing Insulin Sensitivity: It makes cells more responsive to insulin, enabling them to process sugar more efficiently.
These actions facilitate the movement of sugar from the blood into cells, helping to stabilize blood sugar levels. By maintaining steady blood sugar, metformin reduces the risk of long-term complications associated with diabetes, such as nerve and blood vessel damage.
Risks of Excessive Drinking on Metformin
Excessive alcohol consumption while taking metformin can elevate the risk of serious side effects, including lactic acidosis and hypoglycemia. Both conditions can be life-threatening and require immediate medical intervention.
Lactic Acidosis
Metformin increases lactic acid production in the body, while alcohol impairs the liver's ability to clear lactic acid. This combination can lead to lactic acidosis, a rare but dangerous condition characterized by excessive lactic acid buildup in the blood.
Lactic acidosis can cause severe health problems, including hypothermia (low body temperature) and hypotension (low blood pressure). Untreated, it can lead to organ failure.
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Warning signs of lactic acidosis include:
- Muscle pain or cramps
- Extreme fatigue
- Dizziness or feeling cold
- Slow heartbeat
- Stomach pain or discomfort
Seek immediate medical attention if you experience any of these symptoms after drinking alcohol while taking metformin.
Hypoglycemia (Low Blood Sugar)
Metformin lowers blood sugar by reducing the liver's glucose release into the bloodstream. Alcohol can also hinder the liver's glucose release as it prioritizes alcohol processing. Combining metformin with alcohol can result in hypoglycemia, a condition where blood sugar levels become dangerously low.
Common symptoms of hypoglycemia include:
- Shaking
- Sweating
- Fast heartbeat
- Dizziness
- Hunger
- Headache
- Irritability
If you experience symptoms of low blood sugar while drinking, take the following steps:
- Stop drinking immediately.
- Consume fast-acting sugar, such as juice, glucose tablets, candy, or nonfat milk.
- Check your blood sugar again after 15 minutes and repeat if necessary.
In cases of fainting or loss of consciousness, call 911 immediately.
A glucagon emergency kit, available by prescription, can quickly raise blood sugar in emergencies when the person cannot eat or drink. Consider discussing this option with your doctor, especially if you take insulin or have a history of severe low blood sugar.
Additional Side Effects and Interactions
Besides lactic acidosis and hypoglycemia, combining metformin with alcohol can worsen other side effects, such as vitamin B12 deficiency and digestive problems.
Vitamin B12 Deficiency
Both metformin and alcohol can lower vitamin B12 levels, potentially leading to anemia and other health issues over time.
Gastrointestinal (GI) Side Effects
Metformin can cause gastrointestinal side effects like nausea, vomiting, diarrhea, stomach pain, and loss of appetite. Alcohol can exacerbate these issues.
Due to these risks, discussing your alcohol consumption with your doctor is crucial to understand what constitutes moderate drinking and what may be too much.
Metformin and Alcohol: A Case Study
A 65-year-old man with type 2 diabetes being treated with metformin developed lactic acidosis after excessive alcohol consumption. While impaired renal function is a major risk factor for metformin-associated lactic acidosis (MALA), the patient's basal renal function was normal. Alcohol misuse reduces lactate clearance by utilizing nicotinamide adenine dinucleotides for ethanol oxidation, thereby promoting vulnerability to MALA. Nevertheless, as MALA in individuals with a normal renal function is extremely rare, the clinical picture of alcohol-induced MALA is unclear.
The patient's medical history included type 2 diabetes mellitus, alcoholic hepatitis, and chronic pancreatitis. There was no history of chronic kidney disease. The patient was prescribed insulin degludec, metformin, sitagliptin, mitiglinide, and voglibose. The patient had temporarily refrained from consuming alcohol six years ago during his hospitalization for pancreatitis but resumed the habit shortly thereafter. Unfortunately, he did not report persistent alcohol consumption by his physician. The patient had been on leave from work for 1 week because of low back pain syndrome, and his alcohol intake increased 2-fold compared to his normal habit (from 130 g/day to 260 g/day) during this period. The day before the visit, the patient developed anorexia but continued to consume ethanol. He continued to drink on the day of the visit and experienced multiple episodes of vomiting from midday onwards.
Laboratory tests revealed acidemia (pH, 6.97) with a low serum bicarbonate level (7.9 mmol/L) and marked hyperlactatemia (serum lactate, 30.0 mmol/L). The concentration ratio of lactate to pyruvate was also markedly elevated (lactate, 217.7 mg/dL; pyruvate, 3.73 mg/dL; and lactate/pyruvate ratio, 58.4). However, the serum ketone level was mildly elevated (serum ketone, 2.1 mmol/L). Moderate renal impairment (serum creatinine, 1.40 mg/dL; eGFR, 40 mL/min/1.73 m2) and high transaminase levels with aspartate aminotransferase predominance (aspartate aminotransferase, 117 U/L; alanine aminotransferase, 34 U/L) were also observed.
Based on low blood pH (ï¼7.35) and elevated lactate levels (ï¼5.0 mmol/L), the patient was diagnosed with lactic acidosis. The patient was infused with a crystalloid solution under careful monitoring. After the initiation of infusion, serum lactate levels continued to decrease. Metabolic acidosis resolved on day 2 of hospitalization, and serum lactate levels normalized on day 3. Abdominal ultrasonography was performed after the patient's general condition had stabilized. No morphological changes were observed in the liver, suggestive of cirrhosis. The patient was discharged on day 17.
This case illustrates that in patients taking metformin at a regular dose (ï¼2,250 mg/day in Japan), alcohol consumption was ï¼100 g/day. It seems advisable to assume a risk of MALA when the amount of alcohol consumed exceeds 100 g/day.
Recall of Metformin Extended Release
In May 2020, the Food and Drug Administration (FDA) recommended that some makers of metformin extended release remove some of their tablets from the United States market. This is because an unacceptable level of a probable carcinogen (cancer-causing agent) was found in some extended-release metformin tablets. If you currently take this drug, call your doctor. They will advise whether you should continue to take your medication or if you need a new prescription.
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