What is the treatment for metabolic acidosis?

From the Guidelines

The treatment for metabolic acidosis should focus on addressing the underlying cause while correcting the acid-base imbalance, with the most recent guidelines from 2024 suggesting individualization of treatment based on a careful clinical and laboratory assessment 1.

Key Considerations

• The management goals include restoration of circulatory volume and tissue perfusion, resolution of ketoacidosis, and correction of electrolyte imbalance and acidosis.
• In critically ill and mentally obtunded individuals with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), continuous intravenous insulin is the standard of care, as stated in the 2024 guidelines 1.
• Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2–4 h before the intravenous insulin is stopped to prevent recurrence of ketoacidosis and rebound hyperglycemia, a recommendation supported by recent studies 1.

Treatment Approaches

• For mild or moderate DKA, there is no significant difference in outcomes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management, as noted in the 2023 guidelines 1.
• Individuals with uncomplicated DKA may sometimes be treated with subcutaneous rapid-acting insulin analogs in the emergency department or step-down units, an approach that may be safer and more cost-effective than treatment with intravenous insulin, according to the 2024 guidelines 1.
• The use of bicarbonate in patients with DKA is generally not recommended, as several studies have shown it makes no difference in the resolution of acidosis or time to discharge, a finding consistent across guidelines from 2021 1, 2023 1, and 2024 1.

Supportive Care

• Supportive care includes intravenous fluids to restore volume status and electrolyte replacement, particularly potassium, as acidosis correction can lower potassium levels.
• Treatment should be cautious to avoid overcorrection, which can lead to metabolic alkalosis, tetany, or seizures.
• Monitoring of arterial blood gases, electrolytes, and clinical status is essential throughout treatment, as emphasized in the guidelines 1.

From the FDA Drug Label

In cardiac arrest, a rapid intravenous dose of one to two 50 mL vials (44.6 to 100 mEq) may be given initially and continued at a rate of 50 mL (44. 6 to 50 mEq) every 5 to 10 minutes if necessary (as indicated by arterial pH and blood gas monitoring) to reverse the acidosis. In less urgent forms of metabolic acidosis, Sodium Bicarbonate Injection, USP may be added to other intravenous fluids The amount of bicarbonate to be given to older children and adults over a four-to-eight-hour period is approximately 2 to 5 mEq/kg of body weight - depending upon the severity of the acidosis as judged by the lowering of total CO2 content, blood pH and clinical condition of the patient Sodium Bicarbonate Injection, USP is indicated in the treatment of metabolic acidosis which may occur in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or severe dehydration, extracorporeal circulation of blood, cardiac arrest and severe primary lactic acidosis

The treatment for metabolic acidosis is sodium bicarbonate (IV). The dosage and administration of sodium bicarbonate vary depending on the severity and cause of the acidosis.

• In cardiac arrest, a rapid intravenous dose of 44.6 to 100 mEq may be given initially, followed by 50 mL (44.6 to 50 mEq) every 5 to 10 minutes if necessary.
• In less urgent forms of metabolic acidosis, 2 to 5 mEq/kg of body weight may be given over a period of 4 to 8 hours. Treatment of metabolic acidosis should be superimposed on measures designed to control the basic cause of the acidosis 2 2.

From the Research

Treatment of Metabolic Acidosis

The treatment of metabolic acidosis involves addressing the underlying cause of the condition and managing its symptoms. Some key aspects of treatment include:

• Fluid therapy to lower muscle venous Pco2 and ensure effective removal of hydrogen ions by bicarbonate buffer in muscle 3
• Administration of insulin in patients with diabetic ketoacidosis, with careful monitoring of potassium levels to avoid hypokalemia and cardiac arrhythmias 3, 4
• Use of sodium bicarbonate in adult patients with moderately severe acidemia (pH<7.20 and plasma bicarbonate level < 12mmol/L) who are at risk for worsening acidemia, particularly if hemodynamically unstable 3, 5
• Avoidance of sodium bicarbonate administration in children with diabetic ketoacidosis, except in cases of very severe acidemia and hemodynamic instability refractory to saline administration 3
• Consideration of alternative treatments, such as tris(hydroxymethyl)aminomethane (THAM) and selective sodium-hydrogen exchanger 1 (NHE1) inhibitors, which may improve acidosis without producing intracellular acidosis 6

Diagnostic Approach

A systematic approach to diagnosing metabolic acidosis is essential for proper management. This includes:

• Assessment of acid-base parameters, including pH, partial pressure of CO(2) and HCO(3)(-) concentration in arterial blood 7, 6
• Calculation of the serum anion gap and the change from baseline to detect organic acidoses and aid therapeutic decisions 6
• Use of diagnostic algorithms and consideration of ketosis and venous and capillary lactatemia to guide treatment 5

Therapeutic Management

Therapeutic management of metabolic acidosis may involve:

• Insulin therapy in patients with diabetic ketoacidosis, with careful monitoring of glucose and potassium levels 3, 5, 4
• Administration of sodium bicarbonate or alternative treatments, such as THAM, to improve acidosis 3, 5, 6
• Mechanical ventilation in severe cases of metabolic acidosis 5
• Extra-renal purification in some cases of metabolic acidosis 5