The new GOLDMARK Mnemonic For Anion Gap Metabolic Acidosis From Emergency Medicine Cases

This is the link to Best Case Ever 56 Anion Gap Metabolic Acidosis [link is to the podcast and shownotes] from Emergency Medicine Cases.

The case discussion of a 65 yr old woman who presented to the emergency department appearing only mildly ill clinically but turned out to have complex metabolic derangements. The case discussion is approximately 21 minutes long and totally worth listening to. But this post is just about the GOLDMARK mnemonic for differential diagnosis of metabolic acidosis AND about the differential diagnosis of an osmolar gap.

Anion gap = [Na +] – ([Cl -] + [HCO 3 −]) (normal is 12 ± 2) from General Formulas of

Osmolal gap = measured osmoles – calculated osmoles (normal is < 10) from General Formulas of

[Calculated] Osmoles = (2 x [Na +]) + (glucose/18) + (BUN/2.8) + (ethanol/4.6) from General Formulas of

In addition to d-lactate, the D in GOLDMARK can stand for drugs and an article that discusses drugs causing metabolic acidosis is Drug-Induced Metabolic Acidosis [PubMed Abstract] [Full Text HTML] [Full Text PDF]. F1000Res. 2015 Dec 16;4. pii: F1000 Faculty Rev-1460. doi: 10.12688/f1000research.7006.1. eCollection 2015.

What follows below is an excerpt from the show notes that contains a review of the new mnemonic for anion gap metabolic acidosis, GOLDMARK,  and a review of the osmolar gap differential diagnosis:

The MUDPILES mnemonic for anion gap metabolic acidosis is out of date


  • Metabolic acidosis due to paraldehyde overdose is exceedingly rare
  • Iron and isoniazid are just two of many drugs and toxins that cause hypotension and lactic acidosis (isoniazid can also generate a component of ketoacidosis).
  • Three “newer” anion-gap-generating acids have been recognised recently:
    • D-lactic acid, which can occur in some patients with short bowel syndromes.
    • 5-oxoproline (or pyroglutamic acid) associated with chronic acetaminophen use.
    • Propylene glycol infusions – solvent used for several IV medications including lorazepam and phenobarbital.


The GOLDMARK mnemonic for anion gap metabolic acidosis is more useful

GOLDMARK mnemonic for anion gap metabolic acidosis

Glycols (ethylene glycol & propylene glycol)

Oxoproline (metabolite of acetaminophen)


D-lactate (acetaminophen, short bowel syndrome, propylene glycol infusions for lorazepam and phenobarbital)



Renal Failure

Ketoacidosis (starvation, alcohol and DKA)

Osmolar Gap common differential diagnosis

Ketoacids (DKA, AKA, starvation ketosis)




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