From the Guidelines
Thiamine supplementation is crucial in the management of lactic acidosis, particularly in patients with risk factors for thiamine deficiency, and should be administered at a dose of 100-500 mg intravenously, often given as 200 mg IV three times daily for 3-5 days, followed by 100 mg daily until the patient can take oral supplements, as recommended by the most recent guidelines 1. The role of thiamine in the management of lactic acidosis is well-established, as it serves as a critical cofactor for pyruvate dehydrogenase, the enzyme that converts pyruvate to acetyl-CoA in cellular metabolism. When thiamine deficiency occurs, pyruvate cannot enter the Krebs cycle efficiently, resulting in its conversion to lactate and contributing to lactic acidosis. Some key points to consider in the management of lactic acidosis with thiamine include:
- Thiamine supplementation should be initiated before or simultaneously with glucose administration, as giving glucose without thiamine in deficient patients can worsen lactic acidosis by increasing pyruvate production without adequate means to metabolize it 1.
- The treatment is generally safe with minimal side effects, though rare anaphylactic reactions can occur with IV administration 1.
- Thiamine supplementation is particularly important in alcoholic patients, critically ill patients, and those with refractory lactic acidosis, as these populations are at higher risk for thiamine deficiency and lactic acidosis 1. It is essential to note that the use of sodium bicarbonate therapy in the treatment of lactic acidosis is not recommended, as it has not been shown to improve hemodynamics or reduce vasopressor requirements in patients with hypoperfusion-induced lactic acidemia 1. In terms of specific dosing recommendations, the ESPEN micronutrient guideline suggests administering thiamine at a dose of 100-300 mg/day IV in patients admitted to emergency or intensive care, and 100-300 mg/day IV or orally in patients admitted on the ward with suspicion of reduced food intake or high alcohol consumption 1. Overall, thiamine supplementation plays a critical role in the management of lactic acidosis, and its use should be guided by the most recent and highest-quality evidence available 1.
From the FDA Drug Label
Clinical Pharmacology ... The role in carbohydrate metabolism is the decarboxylation of pyruvic acid in the blood and -ketoacids to acetaldehyde and carbon dioxide. Increased levels of pyruvic acid in the blood indicate vitamin B1 deficiency.
The role of thiamine in the management of lactic acidosis is related to its function in carbohydrate metabolism, specifically the decarboxylation of pyruvic acid. Since lactic acidosis is characterized by elevated levels of lactic acid (which is related to pyruvic acid), thiamine may play a role in helping to mitigate this condition by facilitating the conversion of pyruvic acid to acetaldehyde and carbon dioxide. However, the label does not directly state its use for lactic acidosis treatment. 2
From the Research
Role of Thiamine in Lactic Acidosis Management
Thiamine, also known as Vitamin B1, plays a crucial role in the management of lactic acidosis, particularly in cases where the condition is caused by thiamine deficiency. The following points highlight the importance of thiamine in this context:
- Thiamine deficiency can lead to type B lactic acidosis, which may not be as common as type A but is equally critical [(3,4,5,6,7)].
- Recognizing thiamine deficiency-associated lactic acidosis can be challenging due to the lack of routine serum thiamine concentration tests and the need for a thorough patient history 3.
- The appropriate dose and duration of thiamine treatment for lactic acidosis are not well-defined, but studies suggest administering 100 to 200 mg of thiamine intravenously at least once, with ongoing daily doses based on the patient's clinical response 3.
- Untreated thiamine deficiency-associated lactic acidosis can lead to severe illness, requiring life-saving interventions, and may also result in Wernicke encephalopathy or Korsakoff syndrome if not managed properly [(3,4)].
Thiamine Administration and Lactic Acidosis
The administration of thiamine has been shown to improve lactic acidosis in various cases:
- A study reported that thiamine levels were inversely proportional to lactic acidosis, with lower thiamine levels corresponding to higher lactate levels 5.
- Another case study demonstrated that intravenous thiamine administration rapidly controlled lactic acidosis and clinical features in a child with thiamine deficiency 6.
- Thiamine supplementation has also been effective in treating refractory lactic acidosis in non-alcoholic patients, highlighting the importance of considering thiamine deficiency as a potential cause 7.
Recommendations for Thiamine Use
Based on the available evidence, the following recommendations can be made:
- Thiamine deficiency should be considered in every case of severe lactic acidosis without an obvious cause, especially in high-risk populations 4.
- Empiric treatment with thiamine should be initiated immediately when thiamine deficiency is suspected 4.
- Thiamine supplementation should be considered for children with hematological malignancies admitted to intensive care units with low blood pressure and lactic acidosis 5.
- Thiamine deficiency must be suspected and prevented in cases of severe lactic acidosis during parenteral nutrition 6.