HAART-induced lactic acidosis - Revision history

Rossdonaldson1: Text replacement - "Urinalysis" to "Urinalysis"

2018-10-20T23:16:07Z

Text replacement - "*Urinalysis" to "*Urinalysis"

← Older revision		Revision as of 23:16, 20 October 2018
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	*Liver Function Test, as hepatic dysfunction precludes oxidation of lactate, thus resulting in elevated lactate levels in the blood		*Liver Function Test, as hepatic dysfunction precludes oxidation of lactate, thus resulting in elevated lactate levels in the blood
	*Electrolytes		*Electrolytes
	*Urinalysis		*[[Urinalysis]]
	*Lactic Acid level		*Lactic Acid level
	*ABG		*ABG

Rossdonaldson1: /* Disposition */

2017-08-27T00:53:26Z

Disposition

← Older revision		Revision as of 00:53, 27 August 2017
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	==Disposition==		==Disposition==
			*Admit

	==See Also==		==See Also==

Rossdonaldson1: /* See Also */

2017-08-27T00:51:42Z

Rossdonaldson1: /* Differential Diagnosis */

2017-08-27T00:50:56Z

Differential Diagnosis

← Older revision		Revision as of 00:50, 27 August 2017
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	*Sepsis		*Sepsis
	*Ischemia		*Ischemia

			{{HIV associated conditions}}

	==Evaluation==		==Evaluation==

Taleesha at 14:40, 26 August 2017

2017-08-26T14:40:44Z

← Older revision		Revision as of 14:40, 26 August 2017
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	*Normal saline		*Normal saline
	*Anecdotal evidence to support Riboflavin (50mg/day), and/or thiamine (100mg BID) <ref name="Woo" />		*Anecdotal evidence to support Riboflavin (50mg/day), and/or thiamine (100mg BID) <ref name="Woo" />
	*Stop all anti-retrovirals until lactate normalization~~. .~~<ref name="Margolis" />		*Stop all anti-retrovirals until lactate normalization<ref name="Margolis" />
	===Non Emergent===		===Non Emergent===
	*Consider antioixidant supplementation to reduce oxidative stress and hyperlactemia<ref> Lopez O, Bonnefont-Rousselot D, Edeas M, Emerit J, Bricaire F. Could antioxidant supplementation reduce antiretroviral therapy-induced chronic stable hyperlactatemia? Biomed Pharmacother. 2003 May-Jun;57(3-4):113-6. PubMed PMID:12818471.</ref>		*Consider antioixidant supplementation to reduce oxidative stress and hyperlactemia<ref> Lopez O, Bonnefont-Rousselot D, Edeas M, Emerit J, Bricaire F. Could antioxidant supplementation reduce antiretroviral therapy-induced chronic stable hyperlactatemia? Biomed Pharmacother. 2003 May-Jun;57(3-4):113-6. PubMed PMID:12818471.</ref>

Mholtz at 04:07, 26 August 2017

2017-08-26T04:07:43Z

@@ Line 8: / Line 8: @@
 **Impaired electron transport chain, leading to leakage of electrons and increased production of reactive oxygen species.<ref name="Margolis">Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007/s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</ref>
 **Variable onset of mitochondrial toxicity, and not at any set point in NRTI use. <ref name="Margolis" />
 ==Clinical Features==
@@ Line 20: / Line 30: @@
 *Renal abnormalities
 *Since the symptoms are non-specific, most patients present with advanced symptoms and the more serious lactic acidosis. <ref name="Dragovic">Dragovic G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV/AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref>
 ==Differential Diagnosis==

Mholtz at 04:06, 26 August 2017

2017-08-26T04:06:44Z

← Older revision		Revision as of 04:06, 26 August 2017
Line 1:		Line 1:
	==Background==		==Background==
	*Nucleoside Reverse Transcriptase Inhibitors are associated with hyperlactemia and lactic acidosis		*Nucleoside Reverse Transcriptase Inhibitors are associated with hyperlactemia and lactic acidosis
			**NRTI also cause pancreatitis, myopathy, peripheral neuropathy, anemia, neutropenia, hepatic toxicity<ref> Lee WM, Dienstag JL. Lee W.M., Dienstag J.L. Lee, William M., and Jules L. Dienstag.Toxic and Drug-Induced Hepatitis. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J Eds. Dennis Kasper, et al.eds. Harrison's Principles of Internal Medicine, 19e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79748661. Accessed August 22, 2017.</ref>
	**Specifically didanosine (ddI) and stavudine (d4T)		**Specifically didanosine (ddI) and stavudine (d4T)
	**These medicines are no longer first-line agents in the US and Europe, but are in low-middle income countries		**These medicines are no longer first-line agents in the US and Europe, but are in low-middle income countries
	*Adverse effects of NRTI is by way of mitochondrial toxicity.		*Adverse effects of NRTI is by way of mitochondrial toxicity.
	**NRTI inhibit human DNA polymerase gamma, a key enzyme for mitochondrial replication.		**NRTI inhibit human DNA polymerase gamma, a key enzyme for mitochondrial replication.
	**Impaired electron transport chain, leading to leakage of electrons and increased production of reactive oxygen species.<ref>Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007/s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</ref>		**Impaired electron transport chain, leading to leakage of electrons and increased production of reactive oxygen species.<ref name="Margolis">Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007/s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</ref>
	**Variable onset of mitochondrial toxicity, and not at any set point in NRTI use. <ref>Margolis ~~AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007~~/~~s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</ref~~>		**Variable onset of mitochondrial toxicity, and not at any set point in NRTI use. <ref name="Margolis" />

	==Clinical Features==		==Clinical Features==
Line 18:		Line 19:
	*Tachypnea, dyspnea		*Tachypnea, dyspnea
	*Renal abnormalities		*Renal abnormalities
	*Since the symptoms are non-specific, most patients present with advanced symptoms and the more serious lactic acidosis. <ref>Dragovic G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV/AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref>		*Since the symptoms are non-specific, most patients present with advanced symptoms and the more serious lactic acidosis. <ref name="Dragovic">Dragovic G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV/AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref>


	==Risk Factors==		==Risk Factors==
	*Use of stavudine and didanosine containing regimens		*Use of stavudine and didanosine containing regimens
	*CD4 count <200 <ref>Dragovic ~~G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV~~/~~AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref~~>		*CD4 count <200 <ref name="Dragovic" />
	**Additional studies cite a CD4 count less than 500 as a risk factor.<ref>Bonnet F, Balestre E, Bernardin E, Pellegrin JL, Neau D, Dabis F; Groupe d'Epidémiologie Clinique du SIDA en Aquitaine. Risk factors for hyperlactataemia in HIV-infected patients, Aquitaine Cohort, 1999--2003. Antivir Chem Chemother. 2005;16(1):63-7. PubMed PMID: 15739622.</ref>		**Additional studies cite a CD4 count less than 500 as a risk factor.<ref>Bonnet F, Balestre E, Bernardin E, Pellegrin JL, Neau D, Dabis F; Groupe d'Epidémiologie Clinique du SIDA en Aquitaine. Risk factors for hyperlactataemia in HIV-infected patients, Aquitaine Cohort, 1999--2003. Antivir Chem Chemother. 2005;16(1):63-7. PubMed PMID: 15739622.</ref>
	*Female 2.5x male<ref>Dragovic ~~G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV~~/~~AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref~~>		*Female 2.5x male<ref name="Dragovic" />
	*Plasma Triglycerides >2.2mmol/L		*Plasma Triglycerides >2.2mmol/L
	*Age, as the risk of hyperlactemia increases 50% with every 10 years of aging		*Age, as the risk of hyperlactemia increases 50% with every 10 years of aging
Line 30:		Line 32:
	**Associated with dyslipidemia and insulin resistance<ref> Lewis W, Currie PF. HIV/AIDS AND THE CARDIOVASCULAR SYSTEM. In: Fuster V, Harrington RA, Narula J, Eapen ZJ. eds. Hurst's The Heart, 14e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com/content.aspx?bookid=2046&sectionid=155644091. Accessed August 22, 2017.</ref>		**Associated with dyslipidemia and insulin resistance<ref> Lewis W, Currie PF. HIV/AIDS AND THE CARDIOVASCULAR SYSTEM. In: Fuster V, Harrington RA, Narula J, Eapen ZJ. eds. Hurst's The Heart, 14e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com/content.aspx?bookid=2046&sectionid=155644091. Accessed August 22, 2017.</ref>

	==~~DDx~~==		==Differential Diagnosis==
	*Sepsis		*Sepsis
	*Ischemia		*Ischemia
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	==Management==		==Management==
	===Emergent===		===Emergent===
	*Sodium bicarb (judicious doses<ref> Woo OF. Woo O.F. Woo, Olga F.Chapter 23. Antiviral and Antiretroviral Agents. In: Olson KR. Olson K.R. Ed. Kent R. Olson.eds. Poisoning & Drug Overdose, 6e New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com/content.aspx?bookid=391&sectionid=42069837. Accessed August 22, 2017.</ref>)		*Sodium bicarb (judicious doses<ref name="Woo"> Woo OF. Woo O.F. Woo, Olga F.Chapter 23. Antiviral and Antiretroviral Agents. In: Olson KR. Olson K.R. Ed. Kent R. Olson.eds. Poisoning & Drug Overdose, 6e New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com/content.aspx?bookid=391&sectionid=42069837. Accessed August 22, 2017.</ref>)
	*Cessation of offending drug		*Cessation of offending drug
	*Normal saline		*Normal saline
	*Anecdotal evidence to support Riboflavin (50mg/day), and/or thiamine (100mg BID) <ref~~> Woo OF. Woo O.F.~~ Woo, Olga F.Chapter 23. Antiviral and Antiretroviral Agents. In: Olson KR. Olson K.R. Ed. Kent R. Olson.eds. Poisoning & Drug Overdose, 6e New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com/content.aspx?bookid=391&sectionid=42069837. Accessed August 22, 2017.</~~ref~~>		*Anecdotal evidence to support Riboflavin (50mg/day), and/or thiamine (100mg BID) <ref name="Woo" />
	*Stop all anti-retrovirals until lactate normalization. .<ref>Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007/s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</~~ref~~>		*Stop all anti-retrovirals until lactate normalization. .<ref name="Margolis" />
	===Non Emergent===		===Non Emergent===
	*Consider antioixidant supplementation to reduce oxidative stress and hyperlactemia<ref> Lopez O, Bonnefont-Rousselot D, Edeas M, Emerit J, Bricaire F. Could antioxidant supplementation reduce antiretroviral therapy-induced chronic stable hyperlactatemia? Biomed Pharmacother. 2003 May-Jun;57(3-4):113-6. PubMed PMID:12818471.</ref>		*Consider antioixidant supplementation to reduce oxidative stress and hyperlactemia<ref> Lopez O, Bonnefont-Rousselot D, Edeas M, Emerit J, Bricaire F. Could antioxidant supplementation reduce antiretroviral therapy-induced chronic stable hyperlactatemia? Biomed Pharmacother. 2003 May-Jun;57(3-4):113-6. PubMed PMID:12818471.</ref>

	==Disposition==		==Disposition==


	==See Also==		==See Also==
	*NRTI also cause pancreatitis, myopathy, peripheral neuropathy, anemia, neutropenia, hepatic toxicity<ref> Lee WM, Dienstag JL. Lee W.M., Dienstag J.L. Lee, William M., and Jules L. Dienstag.Toxic and Drug-Induced Hepatitis. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J Eds. Dennis Kasper, et al.eds. Harrison's Principles of Internal Medicine, 19e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79748661. Accessed August 22, 2017.</ref>

	==References==		==References==
	<references/>		<references/>

			[[Category:ID]]

Taleesha: /* HAART Induced Lactic Acidosis */

2017-08-25T22:16:56Z

HAART Induced Lactic Acidosis

← Older revision		Revision as of 22:16, 25 August 2017
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	~~=HAART Induced Lactic Acidosis=~~

	==Background==		==Background==
	*Nucleoside Reverse Transcriptase Inhibitors are associated with hyperlactemia and lactic acidosis		*Nucleoside Reverse Transcriptase Inhibitors are associated with hyperlactemia and lactic acidosis

Taleesha: Created page with "=HAART Induced Lactic Acidosis= ==Background== *Nucleoside Reverse Transcriptase Inhibitors are associated with hyperlactemia and lactic acidosis **Specifically didanosine (d..."

2017-08-25T22:16:37Z

Created page with "=HAART Induced Lactic Acidosis= ==Background== *Nucleoside Reverse Transcriptase Inhibitors are associated with hyperlactemia and lactic acidosis **Specifically didanosine (d..."

New page

=HAART Induced Lactic Acidosis=

==Background==
*Nucleoside Reverse Transcriptase Inhibitors are associated with hyperlactemia and lactic acidosis
**Specifically didanosine (ddI) and stavudine (d4T)
**These medicines are no longer first-line agents in the US and Europe, but are in low-middle income countries
*Adverse effects of NRTI is by way of mitochondrial toxicity.
**NRTI inhibit human DNA polymerase gamma, a key enzyme for mitochondrial replication.
**Impaired electron transport chain, leading to leakage of electrons and increased production of reactive oxygen species.<ref>Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007/s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</ref>
**Variable onset of mitochondrial toxicity, and not at any set point in NRTI use. <ref>Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007/s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</ref>

==Clinical Features==
*Fatigue, malaise
*Nausea and or vomiting
*Unexplained mental status changes
*Neurologic Deficits, seizures
*Dysrhythmias
*Heart failure
*Weight gain/weight loss
*Tachypnea, dyspnea
*Renal abnormalities
*Since the symptoms are non-specific, most patients present with advanced symptoms and the more serious lactic acidosis. <ref>Dragovic G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV/AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref>

==Risk Factors==
*Use of stavudine and didanosine containing regimens
*CD4 count <200 <ref>Dragovic G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV/AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref>
**Additional studies cite a CD4 count less than 500 as a risk factor.<ref>Bonnet F, Balestre E, Bernardin E, Pellegrin JL, Neau D, Dabis F; Groupe d'Epidémiologie Clinique du SIDA en Aquitaine. Risk factors for hyperlactataemia in HIV-infected patients, Aquitaine Cohort, 1999--2003. Antivir Chem Chemother. 2005;16(1):63-7. PubMed PMID: 15739622.</ref>
*Female 2.5x male<ref>Dragovic G, Jevtovic D. The role of nucleoside reverse transcriptase inhibitors usage in the incidence of hyperlactatemia and lactic acidosis in HIV/AIDS patients. Biomed Pharmacother. 2012 Jun;66(4):308-11. doi: 10.1016/j.biopha.2011.09.016. Epub 2012 May 15. PubMed PMID: 22658063.</ref>
*Plasma Triglycerides >2.2mmol/L
*Age, as the risk of hyperlactemia increases 50% with every 10 years of aging
*Lipodystrophy and lipoatrophy
**Associated with dyslipidemia and insulin resistance<ref> Lewis W, Currie PF. HIV/AIDS AND THE CARDIOVASCULAR SYSTEM. In: Fuster V, Harrington RA, Narula J, Eapen ZJ. eds. Hurst's The Heart, 14e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com/content.aspx?bookid=2046&sectionid=155644091. Accessed August 22, 2017.</ref>

==DDx==
*Sepsis
*Ischemia

==Evaluation==
*Creatinine clearance, as renal failure is a significant risk factor for the development of lactic acidosis from hyperlactemia. .<ref>Bonnet F, Balestre E, Bernardin E, Pellegrin JL, Neau D, Dabis F; Groupe d'Epidémiologie Clinique du SIDA en Aquitaine. Risk factors for hyperlactataemia in HIV-infected patients, Aquitaine Cohort, 1999--2003. Antivir Chem Chemother. 2005;16(1):63-7. PubMed PMID: 15739622.</ref>
*CBC
*Liver Function Test, as hepatic dysfunction precludes oxidation of lactate, thus resulting in elevated lactate levels in the blood
*Electrolytes
*Urinalysis
*Lactic Acid level
*ABG
*Lipase
*CPK

==Management==
===Emergent===
*Sodium bicarb (judicious doses<ref> Woo OF. Woo O.F. Woo, Olga F.Chapter 23. Antiviral and Antiretroviral Agents. In: Olson KR. Olson K.R. Ed. Kent R. Olson.eds. Poisoning & Drug Overdose, 6e New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com/content.aspx?bookid=391&sectionid=42069837. Accessed August 22, 2017.</ref>)
*Cessation of offending drug
*Normal saline
*Anecdotal evidence to support Riboflavin (50mg/day), and/or thiamine (100mg BID) <ref> Woo OF. Woo O.F. Woo, Olga F.Chapter 23. Antiviral and Antiretroviral Agents. In: Olson KR. Olson K.R. Ed. Kent R. Olson.eds. Poisoning & Drug Overdose, 6e New York, NY: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com/content.aspx?bookid=391&sectionid=42069837. Accessed August 22, 2017.</ref>
*Stop all anti-retrovirals until lactate normalization. .<ref>Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014 Mar;10(1):26-39. doi: 10.1007/s13181-013-0325-8. Review. PubMed PMID: 23963694; PubMed Central PMCID: PMC3951641.</ref>
===Non Emergent===
*Consider antioixidant supplementation to reduce oxidative stress and hyperlactemia<ref> Lopez O, Bonnefont-Rousselot D, Edeas M, Emerit J, Bricaire F. Could antioxidant supplementation reduce antiretroviral therapy-induced chronic stable hyperlactatemia? Biomed Pharmacother. 2003 May-Jun;57(3-4):113-6. PubMed PMID:12818471.</ref>

==Disposition==

==See Also==
*NRTI also cause pancreatitis, myopathy, peripheral neuropathy, anemia, neutropenia, hepatic toxicity<ref> Lee WM, Dienstag JL. Lee W.M., Dienstag J.L. Lee, William M., and Jules L. Dienstag.Toxic and Drug-Induced Hepatitis. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J Eds. Dennis Kasper, et al.eds. Harrison's Principles of Internal Medicine, 19e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79748661. Accessed August 22, 2017.</ref>

==References==
<references/>

← Older revision		Revision as of 00:51, 27 August 2017
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	==See Also==		==See Also==
			*[[Lactic acidosis]]

	==References==		==References==