Lactate Retention

[Guest]

Dr. Garcia,

Several times I've seen you mention that topiramate may cause lactate retention. This seems to be in reference to flu-like symptoms that people have complained of. Could you exlain what lactate retention is, and how it would cause flu symptoms? Also, is there any way to avoid or reduce lactate retention?

Sincerely,
Adria

[Guest]

Lactate Retention

Hi, Adria.

Yes, you are referring to a high lactic level, which can increase the likelihood of lactic acidosis.

First some background: lactic acid comes primarily from muscle tissues and red blood cells. It is a result of sugars used for energy when oxygen levels are low. If a normal amount of oxygen is available, those sugars (carbohydrates) break down into water and carbon dioxide. However the levels can rise for a number of reasons such as heart failure or shock. Very high levels can cause lactic acidosis. These high values are also observed along with severe dehydration, alcohol poisoning, liver disease, extremely strenuous exercise, or medical conditions like lung disease because it prevents oxygen from getting to cells. Some medications like Glucophage and Zerit for diabetics and HIV patients can cause a higher lactic acid level, too. Topamax has been recognized as a medication which may contribute to this condition (as can a severely unbalanced high protein diet.)

You're right, some of the symptoms of lactic acidosis are similar to the flu and can include nausea, vomiting and abdominal pain. As mentioned in Jewell's book, Ortho-McNeil, the manufacturer of Topamax updated its product label and contacted physicians about a type of acidosis called "nonanion gap acidosis". It generally occurs early in treatment, but not always. More serious symptoms include abnormal heart rate or stupor (a trancelike state where someone appears to be numb to everything around them). Others symptoms to watch for include hyperventilation, fatigue or anorexia.

A simple blood test can detect serum bicarbonate levels and if the conditions is indeed found, typically a physician will dose down the medication or titrate the patient off it completely.

Incidentally, anaerobic exercise (the kind that uses muscles at a high intensity for a short period of time) requires more oxygen than the heart and lungs can provide, and results in elevated lactic acid levels in the blood. During aerobic activity, however, (longer term but less intense exercise, such as brisk walking or bicycling) the air you breath has adequate oxygen to provide the body's energy needs. This typically requires about 20 minutes of activity. Some highly trained athletes can tolerate short term/high lactic acid levels. Often individuals combine moderate aerobic training with light anaerobic activities to achieve long term weight loss and improved health.

One of the benefits of regular aerobic exercise with the My Way Out program (versus an unbalanced approach to anaerobic) is a sustained lactic acid level. You'll also benefit from the release of endorphins, which will improve your mood. As stated in the book, three 20-minute sessions per week can be very beneficial. I advise my patients to use a cardio band and jot down the formula for appropriate heart rate which is usually around 220-age x .77.

Talk with your doctor if you have questions about acidosis and request bloodwork if you have concerns. The procedure is very straightforward and called simply a "lactic acid test."

Thanks for the question.

--Dr. Garcia