Stavudine-Induced Hyperlactatemia/Lactic Acidosis at a Tertiary Communicable Diseases Clinic in South Africa

Abstract

Objectives: To determine the incidence, presentation, and outcome of hyperlactatemia and lactic acidosis. Design and Methods Setting: Grey’s Hospital, a tertiary level referral institution. Study Population: A chart review of 1719 patients commenced on highly active antiretroviral therapy (HAART) between August 1, 2004, and July 31, 2006. A total of 1000 patients (615 females) received stavudine (d4T)/lamivudine (3TC)/efavirenz (EFV), 719 patients (598 females) received d4T/ 3TC/nevirapine (NVP). Results: Of the 1719 patients, 152 (8.84%) had an elevated plasma venous lactate (>2.2 mmol/L), 45 patients required admission for lactic acidosis. The overall incidence rate was 13.5 cases per 1000 patient years. The most common presenting symptoms were loss of weight (95%), abdominal pain (78.9%), loss of appetite, and paresthesias (63.8%). The median body mass index (BMI) at commencement of HAART and at onset of symptoms was 24.5 and 26, respectively. A median serum lactate level of 6.08 mmol/L (range 2.3-19.7 mmol/L) was observed at the onset of symptoms. Conclusions: High BMI at treatment initiation did not always predict hyperlactatemia. All patients who died had a baseline CD4 count <10 cells/mm³ at HAART initiation.

Keywords

hyperlactatemia lactic acidosis highly active antiretroviral therapy

References

Ogedegbe AEO , Thomas DL , Diehl AM Hyperlactatemia syndromes associated with HIV therapy. Lancet Infect Dis. 2003;3(6):329-337.

Gerard Y. , Maulin L. , Yazdanpanah Y. , et al. Symptomatic hyperlactatemia: an emerging complication of antiretroviral therapy. AIDS. 2000;14(17):2723-2730.

Grimwood A , ed. National Antiretroviral Therapy Guidelines. Pretoria: Department of Health; 2004. http://www.hst.org.za/publications/624. Accessed February 03, 2008.

John M. , Moore CB , James IR , et al. Chronic hyperlactatemia in HIV infected patients taking antiretroviral therapy. AIDS. 2001; 15(6):717-723.

Boubaker K. , Flepp M. , Sudre P. , et al. Hyperlactatemia and antiretroviral therapy: the Swiss HIV cohort Study. Clin Infect Dis. 2001;33(11):1931-1937.

Moyle GJ , Datta D. , Mandalia S. , Morlese J. , Asboe D. , Gazzard BG Hyperlactatemia and lactic acidosis during antiretroviral therapy: relevance, reproducibility and possible risk factors. AIDS . 2002;16(10):1341-1349.

Moyle G.

Hyperlactatemia and lactic acidosis. Should routine screening be considered?

AIDS Read. 2002;12(8): 344-348.

Brinkman K. Editorial response: hyperlactatemia and hepatic steatosis as features of mitochondrial toxicity of nucleoside analogue reverse transcriptase inhibitors . Clin Infect Dis. 2000; 31(1):167-169.

Brinkman K. Management of hyperlactatemia: no need for routine lactate measurements . AIDS. 2001;15(6):795-797.

10.

Geddes R. , Knight S. , Moosa MY , Reddi A. , Uebel K. , Sunpath H. A high incidence of nucleoside reverse transcriptase inhibitor (NRTI)-induced lactic acidosis in HIV infected patients in a South African context. S Afr Med J. 2006;96(8): 722-724.

11.

Wester CW , Okezie OA , Marlink Richard G. , et al. Higher than expected rates of lactic acidosis among highly active antiretroviral therapy-treated women in Botswana. J Acquir Immune Defic Syndr. 2007;46(3):318-322.

12.

Bolhaar MG , Karstaedt AS A High incidence of lactic acidosis and symptomatic hyperlactatemia in women receiving highly active antiretroviral therapy in Soweto, South Africa . Clin Infect Dis. 2007;45(2):254-260.

13.

Hernández Pérez E. , Dawood H. , Chetty U. , Esterhuizen TM , Bizaree M. Validation of the Accutrend lactate meter for hyperlactatemia screening during antiretroviral therapy in a resource-poor setting. Int J Infect Dis. 2008;12(5):553-556.

14.

Arenas-Pinto A. Risk factors for lactic acidosis and severe hyperlactatemia in HIV-1 infected adults exposed to antiretroviral therapy . Lactic Acidosis International Study Group. AIDS. 2007; 21(18):2455-2464.

15.

Fabian J. , Venter DF , Mkhabela L. , Levin JB , Baker L. , Naicker S. Symptomatic hyperlactatemia in adults on antiretroviral therapy: a single center experience. South African Medical Journal. 2008; 98(10):795-800.