GOLD MARK is a new mnemonic recommended to replace MUDPILES for causes of anion-gap metabolic acidosis
GOLD MARK
- Glycols (propylene glycol and ethylene glycol)
- Oxoproline – 5-oxoproline (or pyroglutamic acid) is associated with chronic acetaminophen use, often by malnourished women.
- L-lactate,
- D-lactate – D-lactic acid can occur in some patients with short bowel syndromes
- Methanol,
- Aspirin,
- Renal failure (vs. uremia)
- Ketoacidosis.
High-dose propylene glycol infusions generate an anion-gap acidosis. Propylene glycol, the solvent used for several parenteral medications including lorazepam, phenobarbital, and others is metabolized to D-lactate and L-lactate.
MUDPILES
Methanol,
Uremia,
Diabetic ketoacidosis,
Paraldehyde,
Iron, isoniazid (INH),
Lactic acid,
Ethanol, ethylene glycol, diethylene glycol, or propylene glycol
Salicylates
KUSMALE is an alternative to MUDPILES that reminds us of Kussmaul respirations that the patient might have. It stands for
Ketoacidosis,
Uremia,
Salicylate poisoning,
Methanol,
Aldehyde (paraldehyde),
Lactate, and
Ethylene glycol.
The argument for switching from MUDPILES to GOLDMARK
- Metabolic acidosis 2/2 excessive paraldehyde use has become exceedingly rare.
- Iron and isoniazid are just two of many drugs and toxins that can cause hypotension and lactic acidosis and thus would be accounted for in the “L” in GOLDMARK. Note that (isoniazid can also generate a component of ketoacidosis.
- Three new organic acids and acid precursors that can lead to an anion gap acidosis have been recognized as causing anion gap metabolic acidosis: 1) D-lactate, 2) 5-oxoproline, 3) propylene glycol
GOLD MARK was first introduced in this Lancet article.