Management of DR-TB ADR: Lactic Acidosis

The mitochondrial toxicity of certain anti-TB drugs, such as in the prolonged use of Linezolid (Lzd) (≥28 days), may cause lactic acidosis which is a potentially life-threatening build-up of lactic acid in the body. It is a serious Adverse Drug Reaction (ADR) that can result in multiorgan failure and death.

Such cases must be immediately referred to the nearest higher health centres - District/ Nodal DR-TB Centre (D/NDR-TBC)/ sub-district or district hospital, medical college hospitals, etc.

Signs and symptoms may include nausea and vomiting, fruity smelling breath, abdominal pain, fatigue, muscle cramps, shallow and rapid breathing, and jaundice (yellowing of the skin or eyes).  

Suspected agent(s): Linezolid (Lzd)

Suggested Management Strategies 

Lactic acidosis is managed at the NDR-TBC as per standard protocols and monitored with a blood test that measures lactic acid.

• Detailed haemogram with other investigations to rule out other causes, and treat any impending cause.
• During prolonged therapy with linezolid, blood pH and lactate levels should be regularly monitored.
• Stop Linezolid if lactic acidosis occurs.
• If there is trouble breathing, oxygen may be delivered with a face mask.
• IV fluids are given to encourage circulation, in some cases, intravenous administration of sodium bicarbonate may be given.
• Peritoneal dialysis or haemodialysis with bicarbonate may also be done, as indicated.

Resources

• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021.
• Ready Reckoner for Medical Officer - Adverse Drug Reactions Associated with Anti-TB Drugs Identification and Management, 2019. ​

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