Is it safe to switch between efavirenz and nevirapine in the event of toxicity?

Mehta, Ushma; Maartens, Gary

doi:10.1016/s1473-3099(07)70262-1

Cited by 40 publications

(33 citation statements)

References 42 publications

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“…Prolonged‐release tablet formulations are available for children > 6 years old and produce a more even drug exposure, but are not suitable for the 14‐day lead‐in phase when starting NVP. Rash is much less common with EFV than with NVP; however, there are insufficient data to recommend switching from NVP to EFV in cases of dermatological hypersensitivity reactions, as repeat rash after substitution has been reported to occur in more than 12% of adult patients 110.…”

Section: Drug Toxicities and Interactionsmentioning

confidence: 99%

Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV‐1 infection 2015: optimizing health in preparation for adult life

et al. 2015

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The 2015 Paediatric European Network for Treatment of AIDS (PENTA) guidelines provide practical recommendations on the management of HIV‐1 infection in children in Europe and are an update to those published in 2009. Aims of treatment have progressed significantly over the last decade, moving far beyond limitation of short‐term morbidity and mortality to optimizing health status for adult life and minimizing the impact of chronic HIV infection on immune system development and health in general. Additionally, there is a greater need for increased awareness and minimization of long‐term drug toxicity. The main updates to the previous guidelines include: an increase in the number of indications for antiretroviral therapy (ART) at all ages (higher CD4 thresholds for consideration of ART initiation and additional clinical indications), revised guidance on first‐ and second‐line ART recommendations, including more recently available drug classes, expanded guidance on management of coinfections (including tuberculosis, hepatitis B and hepatitis C) and additional emphasis on the needs of adolescents as they approach transition to adult services. There is a new section on the current ART ‘pipeline’ of drug development, a comprehensive summary table of currently recommended ART with dosing recommendations. Differences between PENTA and current US and World Health Organization guidelines are highlighted and explained.

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Section: Drug Toxicities and Interactionsmentioning

confidence: 99%

Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV‐1 infection 2015: optimizing health in preparation for adult life

et al. 2015

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“…Three of the four standard ATT drugs and almost all ART drugs are associated with DILI. 19,31,32 Rifampicin can interfere with bilirubin uptake, resulting in unconjugated hyperbilirubinaemia. 11 Pyrazinamide may cause both hepatocellular injury and granulomatous hepatitis.…”

Section: Discussionmentioning

confidence: 99%

Antitubercular therapy induced liver function tests abnormalities in human immunodeficiency virus infected individuals

Puri

Kaur

Pathania

et al. 2017

Medical Journal Armed Forces India

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m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 3 ( 2 0 1 7 ) 1 2 -1Methods: HIV-infected patients diagnosed with TB were evaluated with baseline LFT and CD4 counts. ATT regimen was modified if baseline LFT was significantly abnormal. Patients on protease inhibitors were given rifabutin instead of rifampicin. In patients on nevirapinebased ART, efavirenz was substituted for nevirapine. In ART-naive patients, the timing of introduction of ART was according to CD4 cell counts. LFT were repeated fortnightly or as clinically indicated for 10 weeks. Results:We studied 100 patients with HIV ([M -67, F -23], mean age: 40.05 AE 10.75 years, mean CD4 cell count: 239.157 AE 228.49 cells/dL). Sixty-one patients were on ART prior to diagnosis of TB. Baseline LFT abnormalities (n = 40) were similar in ART and non-ART group (28/61 vs 12/39, p = 0.13). After starting ATT, derangement of LFT was observed in majority of patients (99/100). However, liver sparing ATT was required only in 15 patients. Bilirubin >2.5 mg/dL was seen only in 9 patients. Significant rise in transaminases was commoner in patients on concurrent ART and ATT ( p = 0.044) and with baseline LFT abnormalities ( p = 0.00016). There was no case of acute liver failure or mortality. Conclusion:Mild LFT abnormalities are common in HIV-infected individuals on ATT. Concomitant use of ATT and ART and baseline LFT abnormalities increase the risk of significant DILI. However, with closer follow-up, serious liver injury can be prevented.

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“…Most EFV-induced rashes are mild to moderate with severe rashes (SJS, TEN, EM) reported in only 0·1% of patients, compared with 0·3-1% as reported with NVP. 11,12,[17][18][19] Although female sex and ethnicity are related to the risk of rash with NVP, there is limited data on risk with EFV. 34 Studies by Kiertiburanakul and Sungkanuparph (2009) 35 from Thailand have attributed association of both AIDS-defining illness and high CD4 cell counts at the time of NVP initiation to be associated with NVP-associated rash (Median CD4 cell count at the time of NVP initiation was higher among patients in rash group).…”

Section: Discussionmentioning

confidence: 99%

“…Though the cross reactivity seems higher in the latter group, the number of substitutions from EFV to NVP was seen in only 16 subjects compared with NVP to EFV substitutions in over 239 reported cases. 19 Similarly, in a study conducted on Thai patients in 2006, by Manosuthi et al, only 10 (8.2%) of 122 patients who had NVP rash developed rash from EFV, leading to its discontinuation. 20 Clinical safety data regarding use of NVP in HIV-infected patients with preceding EFV associated rash are still quite limited, 13,21 whereas, switching from NVP to EFV in cases of skin rash or hepatotoxicity have seemed safer and effective.…”

Section: Introductionmentioning

confidence: 95%

“…[14][15][16][17] The incidence of severe rashes with EFV is only 0.1%, compared to 0.3%-1%, as reported with NVP. 11,12,[17][18][19] There are several studies and case reports on the safety of switching of NNRTI in the event of a skin rash. Mehta and Maartens, in a meta-analysis in 2007, observed that recurrent reactions occurred in 12.6% of patients with rash who were switched from NVP to EFV, compared with 50% of those switched from EFV to NVP.…”

Section: Introductionmentioning

confidence: 99%

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Selecting patients who can be re-challenged with Nevirapine in case of skin rash with Efavirenz – A Study

Dutta

Modak

et al. 2017

Sri Lankan J Infec Dis

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Introduction and Objectives: A common adverse effect of Efavirenz (EFV) -a first line drug used in treatment of patients with HIV infections is skin rash. In case of EFV-induced skin rash, the usual practice is to switch to a Protease Inhibitor (PI), as another nonnucleoside reverse transcriptase inhibitor (NNRTI) might have cross-reactivity with a higher incidence of skin rash which is often severe. The aim of the study was therefore to determine whether with careful evaluation and stratification, using predefined criteria of patients who developed rash with EFV, it might be possible to find a subset of patients among whom Nevirapine (NVP) may be safely used, sparing PIs for second-line treatment.

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Is it safe to switch between efavirenz and nevirapine in the event of toxicity?

Cited by 40 publications

References 42 publications

Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV‐1 infection 2015: optimizing health in preparation for adult life

Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV‐1 infection 2015: optimizing health in preparation for adult life

Antitubercular therapy induced liver function tests abnormalities in human immunodeficiency virus infected individuals

Selecting patients who can be re-challenged with Nevirapine in case of skin rash with Efavirenz – A Study

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