Journal of the Association of Nurses in AIDS Care
Clinical Issues ColumnLactic Acidosis Associated With Nucleoside Reverse Transcriptase Inhibitors
Section snippets
Literature Review
Boxwell and Styrt (1999) performed a search of FDA adverse event reports. The authors identified 60 cases of lactic acidosis associated with combination NRTI therapy where lamivudine and stavudine were the predominant combination (60%, n= 36). Among the 36 cases taking lamivudine and stavudine, 20 had died and 85% of these deaths were women. The authors described the population as having a mean age of 40.3 years and a mean weight of 173.2 pounds, and hepatic steatosis (fatty liver) was reported
Case of Lactic Acidosis
A 38-year-old woman with AIDS was admitted to a long-term care facility dedicated to the care of people with AIDS. She had a past medical history of three episodes of bacterial pneumonia, in addition to schizophrenia, substance abuse, herpes simplex virus, and morbid obesity (admission height and weight was 5 feet, 174 lbs, respectively). She was successfully started on antiretroviral therapy with zidovudine, lamivudine, and nelfinavir in July. Her CD4 count remained unchanged (119-105 cells/mm3
Etiology and Risk Factors
NRTIs act by incorporating themselves in viral DNA and inhibiting the phosphorylation system, which is essential for DNA chain elongation. As a result, the viral DNA growth is terminated (Bristol Myers Squibb, 1999; Glaxo Wellcome, 1998a, 1998b, 1999). Although this process is invaluable in stopping viral replication, there is a growing body of evidence that indicates that it also interrupts mitochondrial DNA (mtDNA) replication (Brinkman & ter Hofstede, 1999; Brinkman et al., 1998; Chariot et
Clinical Manifestations
According to Brinkman and ter Hofstede (1999), the clinical course associated with lactic acidosis is characterized by an episode of malaise, nausea, and vomiting, often accompanied by abdominal pain and hyperventilation (compensatory for the acidosis), finally resulting in rapid liver failure and uncontrollable arrhythmias. Nonspecific gastrointestinal symptoms may be seen without a dramatic elevation of hepatic enzymes (U.S. Health and Human Services, 1999). Symptoms of NRTI-induced lactic
Diagnosis
The clinical presentation of NRTI-induced lactic acidosis may mimic other disease entities, and therefore differential diagnosis should include ketoacidosis, uremic acidosis, and ingestion of toxins (Baud & Borron, 1999). Lactic acidosis should be suspected when there is evidence of liver impairment, large tumors with rapid cell turnover, or when patients are on substances such as the NRTIs, which are known to produce this condition (Acosta & Grimsley, 1999). It should also be considered in any
Management
Management of lactic acidosis is directed at early recognition of the condition. To achieve a positive outcome, early diagnosis and prompt withdrawal of nucleoside therapy is essential (Kotler, 1999). When lactic acidosis occurs, treatment is aimed at the cause and supportive measures by replacing fluids to maintain hydration and correcting electrolyte imbalances. Alkali therapy is generally advocated for acute, severe acidemia (pH < 7.1) to improve cardiac function and lactate utilization.
Nursing Implications
Nursing interventions for the patient with lactic acidosis are aimed at early identification, symptom management, supportive therapy, and patient education. Ongoing evaluation of the patient taking NRTIs will assist in determining whether the patient is developing this life-threatening adverse event. Considerations include the population at risk as well as those with prolonged exposure to NRTIs. Ongoing assessment of the AG may assist in early identification.
The broad, nonspecific complaints of
Conclusions
Lactic acidosis is a rare, life-threatening, adverse event of the class of antiretrovirals known as NRTIs. Early recognition is essential because symptoms become rapidly irreversible (Brinkman & ter Hofstede, 1999). The health care prescriber should identify the patient's risk for the development of this adverse event by considering the risk factors of obesity, female gender, and liver disease when prescribing NRTIs. Patient education of this adverse event and its manifestations may assist in
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