Hyperlactataemia and Lactic Acidosis

Diagnosis, Prevention and Management

Risk factors

  • HCV/HBV co-infection
  • Use of ribavirin
  • Liver disease
  • Low CD4 count
  • Pregnancy
  • Female sex
  • Obesity

Prevention/Diagnosis

  • Routine monitoring of serum lactate levels not recommended - does not predict risk of lactic acidosis
  • Measurement of serum lactate, bicarbonate & arterial blood gases + pH indicated in case of symptoms suggestive of hyperlactataemia
  • Close monitoring for symptoms if > 1 risk factor

Symptoms

  • Hyperlactataemia: unexplained nausea, abdominal pain, hepatomegaly, elevated ALT and/or AST, weight loss
  • Acidaemia: asthenia, dyspnoea, arrhythmias
  • Guillain-Barré-like syndrome

 

Management

Serum Lactate
(mmol/L)
Symptoms Action
>5(i) Yes/No
  • Repeat test under standardised conditions to confirm & obtain arterial pH and bicarbonate(i)
  • If confirmed, exclude other causes:
    • Arterial pH ↓ and/or bicarbonate ↓(i): Stop NRTIs
    • Arterial pH and/or bicarbonate normal: Consider switch from high to low risk NRTI and monitor carefully OR stop NRTI
2-5 Yes Exclude other causes; if none found: watchfully follow up OR consider switch from high to low risk NRTI, OR stop NRTI
2-5 No Repeat test. If confirmed, watchfully follow-up
<2   None
i Lactic acidosis is a rare but life-threatening situation usually associated with symptoms; high risk if serum lactate > 5 and especially if > 10 mmol/L

Management of lactic acidosis

  • Irrespective of serum-lactate level
  • Admit the person. Stop NRTIs. Provide iv fluids. Vitamin supplementation can be used (vitamin B complex forte 4 mL bid, riboflavin 20 mg bid, thiamine 100 mg bid; L-carnitine 1000 mg bid), although benefit is not proven