April 2003
Case Description and Question:
The following question comes from a physician in the United States:
I care for a 10-year-old HIV-infected boy who is receiving treatment with stavudine, lamivudine, and efavirenz. He has responded well to treatment and is entirely asymptomatic. Recently, routine blood chemistries revealed a serum bicarbonate concentration of 17 mEq/L. A venous lactate was obtained and measured 12 mmol/L. Given the fact that he is symptom-free, should I make any changes in his antiretroviral therapy?
Answer:
Asymptomatic lactic acidemia (generally defined as plasma lactate greater than 10 mmol/L) may occur in up to 20% of patients receiving at least one nucleoside analog reverse transcriptase inhibitor (NRTI). It has been associated most closely with stavudine-containing treatment. Although the relationship between asymptomatic lactic acidemia and later onset of symptomatic illness is unknown, it is generally recommended that NRTI therapy be stopped in the situation you describe. There is little information on the safety of re-introducing NRTI-containing therapy after an episode of asymptomatic lactic acidemia, but you might wish to consider treatment with NRTIs that produce relatively less inhibition of mitochondrial DNA ploymerase gamma (e.g., zidovudine and abacavir).
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