What is the treatment for lactic acidosis?

From the Guidelines

The primary treatment for lactic acidosis should focus on addressing the underlying cause, with sodium bicarbonate therapy generally not recommended for patients with pH ≥ 7.15, as it does not improve hemodynamics or reduce vasopressor requirements 1. When managing lactic acidosis, it's crucial to differentiate between type A (due to tissue hypoxia) and type B (without tissue hypoxia). For type A, immediate restoration of tissue perfusion and oxygenation is essential through:

• Fluid resuscitation with crystalloids (typically 30 ml/kg bolus initially)
• Vasopressors like norepinephrine (starting at 0.05-0.1 mcg/kg/min)
• Ensuring adequate oxygenation For type B lactic acidosis, treatment targets the specific cause, such as:
• Discontinuing metformin in metformin-associated lactic acidosis, especially in patients with risk factors like significant renal impairment, liver failure, or conditions leading to anaerobic metabolism 1
• Treating the underlying infection Sodium bicarbonate therapy may be considered in severe acidosis (pH < 7.1) at 1-2 mEq/kg over 1-2 hours, though it doesn't improve outcomes and can worsen intracellular acidosis. Other supportive measures include:
• Renal replacement therapy (hemodialysis or continuous venovenous hemofiltration) for severe acidosis unresponsive to other measures, particularly in cases with renal failure or certain drug toxicities
• Thiamine supplementation (100-500 mg IV daily for 3-5 days) in suspected thiamine deficiency Monitoring should include serial lactate levels, arterial blood gases, and hemodynamic parameters to assess response to treatment. It's also important to note that the mortality associated with lactic acidosis correlates with the severity of the underlying condition rather than the degree of acidosis itself, emphasizing the importance of prompt identification and treatment of the primary cause.

From the FDA Drug Label

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 (metformin hydrochloride is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions). 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

The treatment of lactic acidosis involves:

• Immediate discontinuation of metformin hydrochloride tablets
• General supportive measures in a hospital setting
• Prompt hemodialysis to correct the acidosis and remove accumulated metformin 2 Additionally, sodium bicarbonate (IV) is indicated in the treatment of severe primary lactic acidosis 3

From the Research

Treatment of Lactic Acidosis

• The treatment of lactic acidosis, particularly metformin-associated lactic acidosis (MALA), involves addressing the underlying cause of the condition and correcting the acid-base imbalance 4, 5, 6, 7.
• Continuous renal replacement therapy (CRRT) has been shown to be effective in treating MALA, especially in cases complicated by acute kidney injury 4, 6.
• CRRT helps to eliminate metformin, correct acidosis, and maintain fluid balance, thereby improving survival rates 4.
• Prolonged hemodialysis may also be necessary in some cases to remove metformin and correct the acid-base imbalance 5, 7.
• Identifying metformin levels can aid in diagnosis and management, but this is not widely available 5.
• Patients receiving metformin should be counseled to stop the medication and seek medical care in the event of illness, particularly if they are taking other medications that increase the risk of kidney dysfunction 5.

Prevention of Lactic Acidosis

• Prevention is a key factor in managing lactic acidosis, and patients should be aware of the risks of metformin accumulation and the importance of discontinuing the medication in certain situations 4.
• Patients should be educated on the signs and symptoms of lactic acidosis and the importance of seeking medical attention promptly if they occur 5.

Outcomes of Treatment

• With prompt and effective treatment, patients with lactic acidosis can recover fully, but the condition is still associated with high mortality rates if left untreated or if treatment is delayed 4, 5, 6, 7, 8.
• The outcome of treatment depends on various factors, including the severity of the condition, the underlying cause, and the promptness and effectiveness of treatment 4, 5, 6, 7, 8.