Ombitasvir-Paritaprevir-Ritonavir-Dasabuvir (Viekira Pak)-Induced Lactic Acidosis.
OBJECTIVE
To report a case series of three patients with hepatitis C virus infection who all presented with severe type B lactic acidosis shortly after starting treatment with ombitasvir-paritaprevir-ritonavir-dasabuvir.


METHODS
Case series.


METHODS
ICU.


METHODS
Three patients, all who had HCV cirrhosis with mild hepatic impairment (Child-Pugh A) and had started taking ombitasvir-paritaprevir-ritonavir-dasabuvir within the preceding 2 weeks, presented with similar nonspecific symptoms of lethargy, fatigue, and nausea. All had elevated lactate levels at admission without evidence of hypovolemia, cardiogenic failure, or vasodilatory shock.


METHODS
All patients were given appropriate supportive intensive care for what was initially suspected to be sepsis, including a minimum of 30 mL/kg of IV fluids, infectious workup including blood cultures, broad-spectrum antibiotics, and mechanical ventilatory support. The first patient received continuous veno-venous hemofiltration. The second patient received hemodialysis. The third patient was initially started on hemodialysis despite high norepinephrine requirements and ultimately transitioned to continuous veno-venous hemofiltration.


RESULTS
The first patient died despite maximal intensive care. The second patient improved immediately upon starting hemodialysis and was extubated within 48 hours and discharged home. The third patient eventually became hypotensive and was treated with repeated sessions of renal replacement therapy. He ultimately was extubated and discharged home. The infectious workup was negative for all three patients, and antibiotics were discontinued after 2 days in the second and third patients.


CONCLUSIONS
Ombitasvir-paritaprevir-ritonavir-dasabuvir may cause type B lactic acidosis. Further study is warranted to identify risk factors and elucidate the mechanisms of excessive lactate production.
Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
Catherine L
CL
Oberg
Robert J
RJ
Hiensch
Hooman D
HD
Poor
D015081:2-Naphthylamine; D000140:Acidosis, Lactic / Q000139:chemically induced* / Q000628:therapy*; D000813:Anilides / Q000009:adverse effects; D000998:Antiviral Agents / Q000009:adverse effects*; D002219:Carbamates / Q000009:adverse effects; D003521:Cyclopropanes; D004338:Drug Combinations; D005260:Female; D005440:Fluid Therapy; D006440:Hemofiltration; D019698:Hepatitis C, Chronic / Q000150:complications / Q000188:drug therapy*; D006801:Humans; D047029:Lactams, Macrocyclic; D008103:Liver Cirrhosis / Q000821:virology; D047028:Macrocyclic Compounds / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011392:Proline / Q000031:analogs & derivatives; D006435:Renal Dialysis; D012121:Respiration, Artificial; D019438:Ritonavir / Q000009:adverse effects*; D013449:Sulfonamides / Q000009:adverse effects*; D014498:Uracil / Q000009:adverse effects / Q000031:analogs & derivatives*; D014633:Valine
D000813:Anilides; D000998:Antiviral Agents; D002219:Carbamates; D003521:Cyclopropanes; D004338:Drug Combinations; D047029:Lactams, Macrocyclic; D047028:Macrocyclic Compounds; D013449:Sulfonamides; C000607373:Viekira Pak; C586094:ombitasvir; D014498:Uracil; D011392:Proline; D015081:2-Naphthylamine; C588260:dasabuvir; D014633:Valine; D019438:Ritonavir; C585405:paritaprevir