What is the treatment for elevated lactic acid (lactic acidosis)?

From the Guidelines

The treatment for elevated lactic acid, or lactic acidosis, primarily involves addressing the underlying cause while supporting the body's acid-base balance, with the most critical step being the removal of the offending agent or treatment of the underlying condition, as evidenced by the most recent and highest quality study 1.

Key Considerations

• Ensuring adequate tissue oxygenation through supplemental oxygen or mechanical ventilation if needed
• Restoring circulation with intravenous fluids
• Treating any underlying infection with appropriate antibiotics
• For type A lactic acidosis (caused by tissue hypoxia), improving oxygen delivery to tissues is crucial
• For type B lactic acidosis (occurring despite adequate oxygen), removing the offending medication or toxin is essential

Management of Lactic Acidosis

• Discontinuation of metformin and renal replacement therapy (hemodialysis) may be necessary in cases of metformin-associated lactic acidosis
• Thiamine supplementation (100 mg IV) is important for alcohol-related lactic acidosis
• Sodium bicarbonate may be considered for severe acidosis (pH < 7.1) but remains controversial as it can paradoxically worsen intracellular acidosis, as suggested by 1

Fluid Management

• The use of crystalloid for fluid resuscitation is recommended, with specific guidelines for scenarios including hypovolemia, poor peripheral perfusion, and end-organ dysfunction, as outlined in 1
• Clinical reassessment to detect fluid overload and/or pulmonary oedema is crucial, especially in patients with likely fluid intolerance

Renal Replacement Therapy

• Continuous renal replacement therapy or hemodialysis may be required in severe cases unresponsive to conventional treatment, as indicated by 1 and 1

From the FDA Drug Label

In metformin hydrochloride tablets treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin (metformin hydrochloride is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions). If metformin-associated lactic acidosis is suspected, general supportive measures should be instituted promptly in a hospital setting, along with immediate discontinuation of metformin hydrochloride tablets

The treatment for elevated lactic acid (lactic acidosis) involves:

• Discontinuation of the offending agent: Immediate discontinuation of metformin hydrochloride tablets if lactic acidosis is suspected.
• General supportive measures: Institution of general supportive measures in a hospital setting.
• Hemodialysis: Prompt hemodialysis to correct the acidosis and remove accumulated metformin in patients with a diagnosis or strong suspicion of lactic acidosis 2.
• Monitoring and management: Monitoring of blood gases, plasma osmolarity, arterial blood lactate, hemodynamics, and cardiac rhythm, and management of the underlying cause of the acidosis.
• Sodium bicarbonate administration: Administration of sodium bicarbonate may be considered in some cases of metabolic acidosis, but the dosage and administration should be individualized based on the severity of the acidosis and the patient's clinical condition 3.

From the Research

Treatment for Elevated Lactic Acid (Lactic Acidosis)

The treatment for lactic acidosis involves addressing the underlying cause and may include various therapeutic approaches. Some of the key considerations include:

• Identifying and correcting the root cause of lactic acidosis, which could be due to factors such as hypoxia, specific pathologies, use of certain drugs (e.g., metformin), presence of toxins, or trauma 4
• Early recognition and treatment are crucial to prevent poor clinical outcomes, especially in intensive care unit (ICU) patients 4
• Continuous renal replacement therapy (CRRT) may be an effective treatment option for metformin-associated lactic acidosis (MALA) 5, 6
• High-volume venovenous hemofiltration and aggressive alkalinization may also be used to treat severe lactic acidosis 7
• Intravenous administration of sodium bicarbonate has been a mainstay in the treatment of lactic acidosis, but its use should be considered with caution due to potential complications 8
• Other treatment options may include peritoneal dialysis, hemodialysis, and administration of certain medications such as insulin or dichloroacetate 8

Key Treatment Considerations

Some key considerations for treating lactic acidosis include:

• Prompt recognition and diagnosis of lactic acidosis to initiate timely treatment 4, 5
• Identification of the underlying cause of lactic acidosis to guide treatment decisions 4, 5
• Monitoring of lactate levels and acid-base balance to assess treatment effectiveness 5, 7
• Consideration of potential complications and side effects of treatment options, such as hypernatremia or hypervolemia with bicarbonate infusion 8