What is the treatment for persistent lactic acidosis (elevated lactate levels)?

From the Guidelines

Treating persistent lactic acidosis requires addressing the underlying cause while supporting organ function, and the most recent and highest quality study suggests that sodium bicarbonate therapy should be avoided in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15 1. The treatment approach should involve:

• Identifying and treating the primary condition causing the acidosis, such as sepsis, shock, or tissue hypoxia
• Ensuring adequate tissue perfusion by administering intravenous fluids like normal saline or lactated Ringer's at 20-30 ml/kg initially, followed by maintenance fluids based on patient status, as recommended by the Surviving Sepsis Campaign 1
• Maintaining adequate oxygenation with supplemental oxygen or mechanical ventilation if needed
• For sepsis-induced lactic acidosis, starting appropriate antibiotics promptly after obtaining cultures
• In cases of shock, vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min) may be necessary to maintain mean arterial pressure above 65 mmHg, as recommended by the Surviving Sepsis Campaign 1
• Discontinuing medications that may contribute to lactic acidosis, particularly metformin in patients with renal dysfunction, as metformin can increase the risk of lactic acidosis in patients with renal impairment 1
• Considering renal replacement therapy for patients with renal failure or those not responding to conventional treatment
• Monitoring lactate levels, arterial blood gases, and vital signs frequently to assess response to therapy, with the goal of improving tissue perfusion and oxygenation, as lactic acidosis typically resolves when the underlying cause is effectively treated. Key considerations include:
• The use of sodium bicarbonate therapy is controversial and should be avoided in patients with hypoperfusion-induced lactic acidemia with pH ≥ 7.15 1
• Metformin should be used with caution in patients with renal dysfunction, and discontinued if the estimated glomerular filtration rate (eGFR) is less than 30 mL/min per 1.73 m² 1
• The treatment approach should be individualized based on the underlying cause of the lactic acidosis and the patient's clinical status.

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 tablets 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

To treat persistent lactic acidosis, the following steps should be taken:

• Discontinue metformin hydrochloride tablets immediately
• Institute general supportive measures in a hospital setting
• Consider prompt hemodialysis to correct the acidosis and remove accumulated metformin 2

From the Research

Treatment of Persistent Lactic Acidosis

• The treatment of lactic acidosis involves addressing the underlying cause of the condition, as there is no specific treatment for lactic acidosis itself 3.
• Eliminating the triggering conditions, such as sepsis or low-flow states, remains the most effective therapy for lactic acidosis 4.
• Administration of sodium bicarbonate is not recommended, as it can lead to reduction in serum calcium concentration and generation of excess carbon dioxide with intracellular acidification 4.
• Other potential treatments include:
  • Hyperventilation and infusion of calcium during sodium bicarbonate administration 4.
  • Use of other buffers, such as THAM or Carbicarb 4.
  • Dialysis 4, 5.
• In cases of metformin-associated lactic acidosis, treatment may involve:
  • Hemodialysis followed by peritoneal dialysis 5.
  • Continuous bicarbonate infusion 5.
  • Tight glucose control 5.
  • Glucose infusion to counteract suppressed hepatic gluconeogenesis 6.
• It is essential to note that mortality rates associated with lactic acidosis are high, and treatment should be aggressive and tailored to the individual patient's needs 3, 4, 7, 5.