Lactic acidosis and hyperlactatemia associated with lamivudine accumulation and sepsis in a kidney transplant recipient-a case report and review of the literature

Severe Lactic Acidosis Due to Inappropriate Use of Biktarvy in a Patient With AIDS

Bictegravir-emtricitabine-tenofovir alafenamide is an approved medication for the treatment of acquired immunodeficiency syndrome (AIDS). This medication, also called Biktarvy, includes an integrase strand inhibitor combined with nucleoside reverse transcriptase inhibitors (NRTIs) to prevent viral DNA synthesis and lead to improvements in disease progression and mortality in patients with AIDS. A rare but previously documented adverse effect of NRTIs present in Biktarvy is lactic acidosis. NRTIs can cause lactic acidosis through mitochondrial impairment, as mitochondria depend on DNA polymerase gamma for replication. This enzyme is very similar to HIV's reverse transcriptase. Inhibition of mitochondrial production results in increased anaerobic metabolism and lactic acid production. We present a case where an inappropriately high dosage of Biktarvy in a patient with septic shock led to persistent lactic acidosis despite clinical improvement. After a thorough medication review, Biktarvy was temporarily held, and the lactic acidosis resolved. This clinical presentation stresses the importance of maintaining wide differentials for lactic acidosis and thorough medication reconciliation.

Severe lactic acidosis during tenofovir disoproxil fumarate and cobicistat combination for HIV patient

Lactic acidosis is a rare but serious side effect in individuals receiving nucleoside reverse transcriptase inhibitors. An underweight woman with HIV was admitted to our hospital because of nausea and diffuse myalgia. Her antiretroviral regimen had been changed to tenofovir disoproxil fumarate (TDF)/emtricitabine and darunavir/cobicistat 3 months prior, after which her renal function had gradually declined. After admission, she was diagnosed with lactic acidosis, and a liver biopsy suggested mitochondrial damage. Her plasma tenofovir levels were elevated at the onset of lactic acidosis. We hypothesise that the patient's low body weight, combined with the addition of cobicistat, induced renal dysfunction and led to elevated plasma tenofovir concentrations, resulting in mitochondrial damage and lactic acidosis. Careful monitoring of renal function and lactic acidosis is required during use of TDF-containing regimens for underweight HIV patients, particularly when combined with cobicistat.

Antiviral drugs

In this chapter, we have reviewed side effects reported with the use of antivirals for the treatment of the following infections: coronavirus disease 2019 (COVID-19), cytomegalovirus (CMV), hepatitis B virus (HBV), hepatitis C Virus (HCV), herpes simplex viruses 1 and 2 (HSV-1, -2), human immunodeficiency virus (HIV), and influenza virus. The search engines PUBMED, EMBASE and International Pharmaceutical Abstracts (IPA) were utilized to identify literature published between January 1, 2021 to December 31, 2021.