Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

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Management of Medication Toxicity or Intolerance

Lactic Acidosis

Last Updated: April 14, 2020; Last Reviewed: April 14, 2020


General Reviews

  1. Fortuny C, Deya-Martinez A, Chiappini E, Galli L, de Martino M, Noguera-Julian A. Metabolic and renal adverse effects of antiretroviral therapy in HIV-infected children and adolescents. Pediatr Infect Dis J. 2015;34(5 Suppl 1):S36-43. Available at:
  2. Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol. 2014;10(1):26-39. Available at:
  3. Tukei VJ, Asiimwe A, Maganda A, et al. Safety and tolerability of antiretroviral therapy among HIV-infected children and adolescents in Uganda. J Acquir Immune Defic Syndr. 2012;59(3):274-280. Available at:
  4. Bartlett AW, Mohamed TJ, Sudjaritruk T, et al. Disease- and treatment-related morbidity in adolescents with perinatal HIV infection in Asia. Pediatr Infect Dis J. 2019;38(3):287-292. Available at:
  5. Tshamala HK, Aketi L, Tshibassu PM, et al. The lipodystrophy syndrome in HIV-infected children under antiretroviral therapy: a first report from the Central Africa. Int J Pediatr. 2019;2019:7013758. Available at:
  6. Smith ZR, Horng M, Rech MA. Medication-induced hyperlactatemia and lactic acidosis: a systematic review of the literature. Pharmacotherapy. 2019;39(9):946-963. Available at:

Risk Factors

  1. Aperis G, Paliouras C, Zervos A, Arvanitis A, Alivanis P. Lactic acidosis after concomitant treatment with metformin and tenofovir in a patient with HIV infection. J Ren Care. 2011;37(1):25-29. Available at:
  2. Lopinavir/ritonavir (Kaletra) [package insert]. Food and Drug Administration. 2017. Available at:,021906s050lbl.pdf.
  3. Firnhaber C, Smeaton LM, Grinsztejn B, et al. Differences in antiretroviral safety and efficacy by sex in a multinational randomized clinical trial. HIV Clin Trials. 2015;16(3):89-99. Available at:
  4. Fortuin-de Smidt M, de Waal R, Cohen K, et al. First-line antiretroviral drug discontinuations in children. PLoS One. 2017;12(2):e0169762. Available at:
  5. Lim TY, Poole RL, Pageler NM. Propylene glycol toxicity in children. J Pediatr Pharmacol Ther. 2014;19(4):277-282. Available at:
  6. Mamiafo CT, Moor VJ, Nansseu JR, Pieme CA, Tayou C, Yonkeu JN. Hyperlactatemia in a group of HIV patients living in Yaounde-Cameroon. AIDS Res Ther. 2014;11(1):2. Available at:
  7. Matthews LT, Giddy J, Ghebremichael M, et al. A risk-factor guided approach to reducing lactic acidosis and hyperlactatemia in patients on antiretroviral therapy. PLoS One. 2011;6(4):e18736. Available at:
  8. Moren C, Noguera-Julian A, Garrabou G, et al. Mitochondrial evolution in HIV-infected children receiving first- or second-generation nucleoside analogues. J Acquir Immune Defic Syndr. 2012;60(2):111-116. Available at:
  9. Tetteh RA, Nartey ET, Lartey M, et al. Association between the occurrence of adverse drug events and modification of first-line highly active antiretroviral therapy in Ghanaian HIV patients. Drug Safety. 2016;39(11):1139-1149. Available at:
  10. Wester CW, Eden SK, Shepherd BE, et al. Risk factors for symptomatic hyperlactatemia and lactic acidosis among combination antiretroviral therapy-treated adults in Botswana: results from a clinical trial. AIDS Res Hum Retroviruses. 2012;28(8):759-765. Available at:

Monitoring and Management

  1. Barlow-Mosha L, Eckard AR, McComsey GA, Musoke PM. Metabolic complications and treatment of perinatally HIV-infected children and adolescents. J Int AIDS Soc. 2013;16:18600. Available at:
  2. Claessens YE, Cariou A, Monchi M, et al. Detecting life-threatening lactic acidosis related to nucleoside-analog treatment of human immunodeficiency virus-infected patients, and treatment with L-carnitine. Crit Care Med. 2003;31(4):1042-1047. Available at:
  3. Kraut JA, Madias NE. Lactic acidosis. N Engl J Med. 2014;371(24):2309-2319. Available at:
  4. Marfo K, Garala M, Kvetan V, Gasperino J. Use of Tris-hydroxymethyl aminomethane in severe lactic acidosis due to highly active antiretroviral therapy: a case report. J Clin Pharm Ther. 2009;34(1):119-123. Available at:
  5. Jung B, Martinez M, Claessens YE, et al. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care. 2019;9(1):92. Available at:

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