Longitudinal lactate levels from routine point-of-care monitoring in adult Malawian antiretroviral therapy patients: associations with stavudine toxicities.
BACKGROUND
Stavudine is still widely used in under-resourced settings such as Malawi due to its low price. It frequently causes peripheral neuropathy and lipodystrophy and increases the risk of lactic acidosis and other high lactate syndromes.


METHODS
We studied the association of longitudinal lactate levels, obtained by routine, 3-monthly point-of-care monitoring, with peripheral neuropathy, lipodystrophy and high lactate syndromes in adult Malawians who were in the second year of stavudine containing antiretroviral therapy (ART).


RESULTS
Point-of-care lactate measurements were feasible in a busy urban ART clinic. Of 1170 lactate levels collected from 253 patients over the course of one year, 487 (41.8%) were elevated (>2.2mg/dl), 58 (5.0%) were highly elevated (>3.5mg/dl). At least one elevated lactate level occurred in 210 (83.0%) of patients and sustained hyperlactatemia in 65 (26.4%). In random effects analyses lipodystrophy and peripheral neuropathy were associated with higher lactate levels. Only five patients developed high lactate syndromes (one lactic acidosis) of whom no preceding lactate measurements were available because events had started before enrolment. Lactate levels significantly decreased over time and no high lactate syndromes were observed after the 15th month on ART.


CONCLUSIONS
Lipodystrophy and peripheral neuropathy were associated with higher lactate levels. Lactate levels decreased over time, coinciding with absence of new high lactate syndromes after the 15th month on ART.
Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine.
Newton
N
Chagoma
Jane
J
Mallewa
Symon
S
Kaunda
Yasin
Y
Njalale
Elizabeth
E
Kampira
Mavuto
M
Mukaka
Robert S
RS
Heyderman
Joep J
JJ
van Oosterhout
D000140:Acidosis, Lactic / Q000139:chemically induced / Q000175:diagnosis; D000328:Adult; D019380:Anti-HIV Agents / Q000009:adverse effects* / Q000191:economics / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects; D015331:Cohort Studies; D016527:Drug Costs; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006801:Humans; D019344:Lactic Acid / Q000032:analysis* / Q000378:metabolism; D008060:Lipodystrophy / Q000139:chemically induced / Q000175:diagnosis; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008507:Medically Underserved Area; D010523:Peripheral Nervous System Diseases / Q000139:chemically induced / Q000175:diagnosis; D019095:Point-of-Care Systems; D011446:Prospective Studies; D018119:Stavudine / Q000009:adverse effects* / Q000191:economics / Q000627:therapeutic use
D019380:Anti-HIV Agents; D019344:Lactic Acid; D018119:Stavudine
Antiretroviral therapy; HIV; Lactate; Malawi; Monitoring; Stavudine; Toxicity