Hyperlactic Acidosis as Metabolic Side-Effect of Albuterol and Theophylline in Acute Severe Asthma

Discussion ▼ The most common acid-base disturbance associated with exacerbation of asthma is respiratory alkalosis (Mountain RD et al. Chest 1990; 98: 651 – 655). With increasing bronchospasm retention of carbon dioxide results in respiratory acidosis. A further acid-base abnormality accompanying acute asthma is lactic acidosis, which is mostly considered to result from bronchospasm which causes tissue hypoxia or release by overloaded respiratory muscles; other common reasons in unwell patients are cardiovascular collapse or sepsis (Mountain RD et al. Chest 1990; 98: 651 – 655; Creagh-Brown BC et al. Am J Emerg Med 2008; 26: 514.e1 – e3). But there is evidence that hyperlactatemia in acute asthma may be caused by albuterol or theophylline as an adverse side-eff ect (Creagh-Brown BC et al. Am J Emerg Med 2008; 26: 514.e1 – e3; Koh YI et al. Korean J Intern Med 2002; 17: 147 – 149). Based on our laboratory data and in absence of other common reasons men tioned above we think this side-effect of bronchodilator therapy is a plausible cause for lactic acidosis in our patient. The metabolic investigations in our patient largely exclude genetic defects of intermediary metabolism that could lead to hyperlactic acidosis. The markedly increased lactate concentration in plasma together with a normal L / P ratio rather indicate a transient disturbance of pyruvate metabolism and argue strongly against primary or secondary disturbances of oxidative phosphorylation, e. g. due to compromised oxygen supply to tissues. Our results demonstrate an acute accumulation of pyruvate leading to a corresponding accumulation of lactate. This fi nding is compatible with an inhibition of pyruvate dehydrogenase activity by FFA leading to inhibited conversion of pyruvate to acetyl-coenzyme A with subsequent lactate accumulation as shown in ● ▶ Fig. 1 (Holness MJ et al. Biochem Soc Trans 2003; 31: 1 143 – 1 151). FFA can be massively released during stress. StimulaAbbreviations ▼