Can Solumedrol Increase Lactic Acid Levels?
Yes, methylprednisolone (Solumedrol) can cause hyperlactatemia and lactic acidosis, though this is a rare adverse effect that represents type B (non-ischemic) lactic acidosis rather than tissue hypoperfusion.
Mechanism and Clinical Evidence
Methylprednisolone can induce elevated lactate levels through metabolic disturbances rather than tissue hypoxia. 1 This represents type B lactic acidosis, which occurs without hypoperfusion due to metabolic disturbances or drug toxicity. 2
- Case documentation: A 19-year-old patient developed lactic acidosis shortly after receiving high-dose methylprednisolone for spinal cord injury, with lactate levels returning to baseline after steroid discontinuation. 1
- Pediatric case: A 5-year-old with severe asthma developed lactic acidosis following treatment with methylprednisolone (along with theophylline and albuterol), confirmed by elevated serum lactate and increased anion gap. 3
- Systematic review findings: Medication-induced lactate elevations are diagnoses of exclusion that can be overlooked, with 64% of cases classified as lactic acidosis and 16% mortality rate across all medication-induced cases. 4
Diagnostic Approach When Suspecting Steroid-Induced Lactic Acidosis
First, rule out type A (hypoperfusion) causes:
- Assess hemodynamic status for shock, sepsis, or tissue hypoperfusion 2
- Evaluate for circulatory disorders including cardiac failure 2
- Check for severe infections, particularly in diabetic patients 2
Laboratory confirmation:
- Arterial pH <7.35 with elevated anion gap (>16) suggests lactic acidosis 2
- Blood lactate >2 mmol/L is elevated; >5 mmol/L is abnormal; >10 mmol/L is life-threatening 2
- Calculate anion gap: Na - (Cl + CO₂) >16 2, 3
- Use prechilled fluoride-oxalate tubes, transport on ice, and process within 4 hours 2
Exclude other medication causes:
- Review for metformin use (especially with eGFR <30 mL/min/1.73m²) 5, 6
- Check for nucleoside reverse transcriptase inhibitors in HIV patients 2
- Consider other sympathomimetics like epinephrine or albuterol 4, 3
Management Strategy
Immediate actions:
- Discontinue or reduce methylprednisolone dose if type B lactic acidosis is confirmed and type A causes are excluded 1
- Continue supportive care while monitoring lactate trends 2
- Do NOT use sodium bicarbonate for pH ≥7.15, as it does not improve hemodynamics and may worsen outcomes 2
Monitoring approach:
- Repeat lactate measurement within 6 hours to assess trend 2
- Monitor for progression or resolution after steroid adjustment 1
- Watch for clinical symptoms: gastrointestinal distress, tachypnea, dyspnea, weakness, or confusion 2
Critical Clinical Pitfalls
Do not assume all lactic acidosis is from hypoperfusion. Type B lactic acidosis from medications can occur in hemodynamically stable patients with normal tissue perfusion. 1 The combination of methylprednisolone with other agents (theophylline, beta-agonists) may compound the risk. 3
Do not delay recognition. Subtle early symptoms like nonspecific gastrointestinal complaints, dyspnea, and generalized weakness often precede severe acidosis and should prompt lactate measurement. 2
Consider the clinical context. In patients receiving high-dose methylprednisolone who develop unexplained lactate elevation without signs of shock or sepsis, medication-induced type B lactic acidosis should be high on the differential. 1 Pharmacists should be consulted as they are well-positioned to identify medication-induced lactate elevations. 4