From the Guidelines
The management of lactic acidosis should focus on treating the underlying cause and providing supportive care, with sodium bicarbonate therapy generally reserved for severe cases (pH < 7.1) due to limited evidence supporting its routine use 1.
Key Principles of Management
- Identify and address the primary condition causing lactic acid buildup, such as sepsis, shock, severe hypoxemia, or medication toxicity.
- Ensure adequate tissue oxygenation by maintaining airway, breathing, and circulation.
- Administer intravenous fluids (typically crystalloids like normal saline) to restore intravascular volume and improve tissue perfusion.
- For sepsis-induced lactic acidosis, prompt administration of appropriate antibiotics is essential.
- In cases of shock, vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) may be necessary to maintain adequate blood pressure and tissue perfusion.
- Discontinue medications that may contribute to lactic acidosis, such as metformin.
Considerations for Specific Patient Groups
- In patients with mitochondrial disease, meticulous individual assessment is crucial, and the routine use of lactate-free IV fluids is recommended to prevent exacerbation of lactic acidosis 1.
- For patients undergoing continuous renal replacement therapy (CRRT), either lactate or bicarbonate can be used as a buffer, but bicarbonate is preferred in patients with lactic acidosis and/or liver failure 1.
Monitoring and Adjunctive Therapies
- Continuous monitoring of lactate levels, arterial blood gases, and vital signs is crucial to assess response to treatment.
- In refractory cases, renal replacement therapy may help clear lactate and correct acidosis.
- The effectiveness of management depends on addressing the underlying pathophysiology causing oxygen supply-demand mismatch or altered cellular metabolism that leads to lactic acid accumulation.
From the FDA Drug Label
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 extended-release tablets In metformin hydrochloride extended-release tablets treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin If metformin-associated lactic acidosis is suspected, immediately discontinue metformin hydrochloride extended-release tablets and institute general supportive measures in a hospital setting. Prompt hemodialysis is recommended
The management of lactic acidosis includes:
- Immediate discontinuation of metformin
- General supportive measures in a hospital setting
- Prompt hemodialysis to correct the acidosis and remove accumulated metformin 2, 2
From the Research
Management of Lactic Acidosis
The management of lactic acidosis involves several approaches, including:
- Correcting the underlying cause of the condition 3, 4, 5, 6, 7
- Optimizing oxygen delivery to the tissues 3
- Using renal replacement therapy, such as continuous renal replacement therapy (CRRT) or dialysis, to remove excess lactate and correct metabolic acidosis 3, 4, 5
- Administering sodium bicarbonate to alkalinize the blood, although its use is controversial and not universally recommended 3, 6, 7
- Using other therapeutic modalities, such as peritoneal dialysis, hemodialysis, and insulin therapy, depending on the underlying cause and severity of the condition 4, 5, 7
Treatment Options
Some specific treatment options for lactic acidosis include:
- High-volume venovenous hemofiltration, which can remove excess lactate and correct metabolic acidosis 4
- Aggressive alkalinization therapy, which can help control severe acidosis 4
- Dual CRRT, which may be an effective alternative to intermittent hemodialysis in some cases 5
- Sodium bicarbonate administration, although its use should be considered with caution due to potential complications 6, 7
- Insulin therapy, which may be useful in the treatment of phenformin-associated lactic acidosis 7
- Dichloroacetate, which may be a useful adjunct in the treatment of lactic acidosis due to its ability to activate pyruvate dehydrogenase and enhance lactate metabolism 7