{"id":3943,"date":"2000-10-17T08:14:16","date_gmt":"2000-10-17T07:14:16","guid":{"rendered":"http:\/\/moomango.co.uk\/htb\/?p=3943"},"modified":"2017-02-07T00:02:18","modified_gmt":"2017-02-07T00:02:18","slug":"lactic-acidosis","status":"publish","type":"post","link":"https:\/\/i-base.info\/htb\/3943","title":{"rendered":"Lactic acidosis"},"content":{"rendered":"<p><strong>Simon Collins, HIV i-Base<\/strong><\/p>\n<p><strong>Increases in the level of lactic acid have been recognised in both HIV-positive adults and children and is linked to all nucleoside analogues as well as in people not using ARV treatment<\/strong> [1, 2].<\/p>\n<p>More seriously, lactic acidosis (LA) can be fatal in over half the reported cases. Attention was focused on this with the recent FDA requirement for a new emphasis on this in product information summaries and advertising for abacavir, d4T and ddI. Two posters on lactic acid were presented at the Lipodystrophy workshop.<\/p>\n<p>Kees Brinkman presented a poster on a protocol for treatment of LA [3] based on incomplete case reports (using riboflavin, L-carnitine and co-enzymeQ [4]). This involves:<\/p>\n<ul>\n<li>Stopping NRTI treatment immediately<\/li>\n<li>Start treatment with viramin B complex forte 4 ml (i.v.) BID (per 2 ml ampulle: 50 mg thiamine, 10mg riboflavine, 100mg nicotinamide, 10 mg pyridoxine, 10mg dexpanthenol)<\/li>\n<li>L-carnitine 1000mg (i.v.) BID<\/li>\n<\/ul>\n<p>Treatment should be continued until lactate levels fall below 3 mmol\/l. Oral continuation of treatment can be considered.<\/p>\n<p>Six patients were treated using this protocol in the Netherlands between November 1999-June 2000. Background NTRI therapy was ddI\/d4T\/HU in three patients (duration 9, 9 and 17 months), d4T\/3TC in one (11 mo), d4T\/ddI (&gt;12mo) in one and DDI\/HU\/3TC\/abacavir (11.5mo) in one. Clinical syndrome included nausea, vomiting, abdominal complaints, liver failure, pancreatitis; lactate &gt;5 mmol\/l, bicarbonate &lt;20 mmol\/l.<\/p>\n<p>All patients recovered, although one elected to stop all treatment after 6 days (with lactate 4.4 mmol\/l) and died 3 days later. Normalisation to &lt;3 mmol\/l occurred from 4-over 20 days &#8211; the 20-day resolution being in a patient that used oral B1, B2 complex rather than i.v. administration.<\/p>\n<p>While not all cases of LA prove fatal, and early recognition of symptoms and discontinuation of NRTIs alone may have been responsible for the favourable outcome, this non-toxic intervention would seem to be a simple and prudent measure for patients presenting with lactic acidosis. Dr Brinkman commented that although prospective randomised trials would be useful they are hardly imaginable in this setting.<\/p>\n<p>Early diagnosis is clearly critical, and Y Gerard from the Infectious Diseases Dept, University Tourcoing, France presented a poster recommending routine measurement of anion gap (AG) to allow for early recognition of symptoms [5]. A similar study from Johns Hopkins was also presented at the Retrovirus conference earlier this year [6].<\/p>\n<p>AG was routinely measured every two months since March 2000 in a prospective study involving the whole cohort at this clinic (2065 AG measurements in 806 patients). AG was calculated as ([Na+K]-Cl+CO2]) and defined as high when &gt;20. Twelve patients developed AG&gt;20 (1.5%) all of whom were using HAART. A statistically significant difference was found between use of background NRTIs with 10\/374 patients using d4T (2.7%) and 1\/326 using AZT (0.3%). Three of these patients were then found to have lactic acidosis, however, AG was elevated in only half the patients who presented with high lactate levels.<\/p>\n<p>One case of lactic acidosis was diagnosed with a high AG of 30.3 (lactate 9 mmol\/l) which resolved following discontinuation of ARVs and administration of carnitine, riboflavin, vitamin C, E and co-enzyme Q. Treatment was also interrupted in another with AG of 25.8 (lactate 4.2 mmol\/l). Three patients also normalised AG in whom elevated lactate was detected while continuing on the same treatment.<\/p>\n<p>References:<\/p>\n<ol>\n<li>Montaner, J et al &#8211; Screening for Nucleoside-Associated Lactic Acidosis. Abstract TuPpB1233. XIII World AIDS Conference, Durban, 2000.<\/li>\n<li>Church, J et al &#8211; Near-Fatal Metabolic Acidosis, Liver Failure in Mitochondrial DNA Depletion in an HIV-infected Child Treated with Combination ARV Therapy.Abstract 58. 7th CROI, 2000. http:\/\/www.retroconference.org\/2000\/abstracts\/58.htm<\/li>\n<li>Brinkman, K et al &#8211; Treatment of Lactic Acidosis. Abstract P15. 2nd Intl Workshop on Adverse Drug Interactions and Lipodystrophy, Toronto, Sep 2000.<\/li>\n<li>Riboflavin: Fouty et al (Lancet 1998) and Luzatti et al (Lancet, 1999). L-carnitine: Cloosens et al (AIDS, 2000). Co-enzyme Q: Lenzo et al (AIDS 1997) and John S (AIDS, 2000).<\/li>\n<li>Gazzard, Y et al &#8211; Early Diagnosis of Lactic Acidosis in HIV-infected Adults Receiving ARVs: Anion Gap Measurement. Abstract P19. 2nd Intl Workshop on Adverse Drug Interactions and Lipodystrophy, Toronto, Sep 2000.<\/li>\n<li>Moore, R et al &#8211; Differences in Anion Gap with Different NRTI Combinations. Abstract 55. 7th CROI, 2000.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Simon Collins, HIV i-Base Increases in the level of lactic acid have been recognised in both HIV-positive adults and children and is linked to all nucleoside analogues as well as in people not using ARV treatment [1, 2]. More seriously, &hellip;<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4,8],"tags":[121],"class_list":["post-3943","post","type-post","status-publish","format-standard","hentry","category-conference-reports","category-side-effects","tag-lipo-2nd-2000"],"_links":{"self":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/3943","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/comments?post=3943"}],"version-history":[{"count":0,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/posts\/3943\/revisions"}],"wp:attachment":[{"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/media?parent=3943"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/categories?post=3943"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/i-base.info\/htb\/wp-json\/wp\/v2\/tags?post=3943"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}