[Safety of atazanavir in patients with HIV and hepatitis B and/or C virus coinfection]

Hyperbilirubinaemia in HIV-HCV co-infected patients on antiretroviral therapy: drug effect or liver disease severity?

Objective

Hyperbilirubinaemia (HB) is common in HIV and hepatitis C virus (HIV–HCV) co-infected patients and poses a unique challenge in management as it may be due to medications such as the protease inhibitors (PIs) or to hepatic dysfunction. There are no data on the relationship of HB to liver histology and PI use in this population. Clinicians caring for these patients are faced with the difficult task of determining whether increasing serum bilirubin is due to drug effects or progression of liver disease.

Methods

To address this gap in knowledge, we performed a retrospective analysis of 344 consecutive HIV–HCV co-infected patients undergoing liver biopsy to identify factors associated with HB. Demographic, clinical, laboratory data were collected. Advanced fibrosis was defined as bridging fibrosis or cirrhosis. Those with hepatitis B virus, hepatic decompensation or hepatocellular carcinoma were excluded.

Results

The prevalence of HB (range 1.3–9.4) was 33% and more common in those on a PI (46%) than those who were not (10%; p≤0.001) and mostly in those on indinavir (40%) or atazanavir (46%). Of the patients on these PIs, HB was not associated with fibrosis grade, demographics, or other clinical variables. Conversely, in those not on a PI, HB was associated with fibrosis grade (p≤0.0001) after adjusting for other clinical and demographic variables.

Conclusions

In the setting of indinavir or atazanavir use, HB is common and unrelated to underlying disease severity and the medications can be continued safely. Conversely, HB in HIV–HCV co-infected patients not on a PI is due to their underlying liver disease and suggests these patients require closer monitoring.

[Clinical utility of atazanavir]

Atazanavir (ATV) is a protease inhibitor (PI) in which its main qualities, compared to other PI are dosing convenience, good tolerability and excellent metabolic profile. These characteristics makes it more like a nonnucleoside than a PI, but with the increased genetic barrier common to PI. It is indicated in initial treatment, simplification treatment or a change due to toxicity and in first line rescue treatment. The administering of ATV boosted with ritonavir (300/100 mg/d) has been approved in Europe in all clinical situations. In naïve patients it has been combined with practically all the nucleoside analogue pairs and has shown to be as effective as lopinavir/ritonavir and even efavirenz. In the USA, this indication has been approved for almost 5 years and ATV has become the most prescribed PI, while the EMEA has approved it this year. ATV is an optimal drug to replace other antiretrovirals in simplification strategies or changes due to toxicity. In several studies it has been shown that, in patients with good virological control, it can LPV/r or another PI, the therapeutic efficacy being maintained, with excellent tolerance and an improved lipid profile, and decreasing the cardiovascular risk. This strategy is widely used in Spain. In this scenario some patients could benefit from non-boosted ATV treatment (400 mg/d). ATV is an effective and very attractive option in first line rescue treatments in which the virus shows little or no resistance to PI, as its simplicity and tolerability can improve problems with compliance, the main cause of therapeutic failure. In patients with moderate resistance to PI, ATV is as effective as LPV/r. The survival of patients with HIV infection is increasingly longer and factors such as tolerability, cardiovascular risk and the adaptability of the treatment to the lifestyle of the patient, become more important, therefore ATV must play an important role in the treatment of HIV-infection.