Metformin, the most widely prescribed oral hypoglycemic agent for type 2 diabetes, is generally regarded as safe and effective. Nevertheless, metformin-associated lactic acidosis (MALA) remains a rare but life-threatening complication, especially in patients with impaired renal function or acute intercurrent illness. This review aims to synthesize recent epidemiological evidence, mechanistic understanding, and clinical management strategies for MALA, drawing on large cohort studies, case series, and up-to-date guidelines. Although the incidence of MALA is low, the associated mortality remains substantial, underscoring the need for vigilant risk assessment, timely diagnosis, and prompt intervention. Recent data have refined our understanding of risk stratification, revealing that renal dysfunction, acute kidney injury, and critical illness are key predisposing factors. Advances in supportive care and renal replacement therapies have improved outcomes, but prevention through safe prescribing and patient education remains paramount.