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Fluctuating hormones might also be to blame

GRAPHICAL ABSTRACT Highlights Acidifying non- Saccharomyces yeasts: Lachancea thermotolerans

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Clinical recommendations based upon the patient's renal function include [see Dosage and Administration (2.2), Clinical Pharmacology (12.3)]: Drug Interactions The concomitant use of JANUMET XR with specific drugs may increase the risk of metformin-associated lactic acidosis: those that impair renal function, result in significant hemodynamic change, interfere with acid-base balance or increase metformin accumulation [see Drug Interactions (7)]