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Arnouk S, Whitsett M, Papadopoulos J, Stewart Lewis Z, Dagher NN, Feldman DM, Park JS. Successful Treatment of Tenofovir Alafenamide-Induced Lactic Acidosis: A Case Report. J Pharm Pract 2023; 36:1260-1263. [PMID: 35635046 DOI: 10.1177/08971900221105042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Nucleoside or nucleotide analogues (NAs) have the potential to cause lactic acidosis by inhibiting DNA polymerase-γ of human mitochondria and impairing aerobic metabolism. Patients may be asymptomatic, have mild non-specific symptoms, or present in multisystem organ failure. There is a paucity of data to guide management of life-threatening lactic acidosis due to NA therapy. Here we describe a case of a 60-year old critically ill male with decompensated cirrhosis secondary to hepatitis B virus (HBV) infection who developed severe lactic acidosis (13.8 mmol/L) 2 days after initiation of tenofovir alafenamide (TAF). All other possible etiologies for the elevated lactate were ruled out. Lactic acidosis resolved rapidly with TAF discontinuation and supplementation with cofactors supporting mitochondrial oxidative phosphorylation, including coenzyme Q10, levocarnitine, riboflavin, and thiamine. This case highlights the ability of TAF to cause lactic acidosis early after therapy initiation, especially in susceptible hosts, and reviews the potential role for cofactor supplementation for drug-induced mitochondrial injury.
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Affiliation(s)
- Serena Arnouk
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Maureen Whitsett
- Department of Transplant Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Nabil N Dagher
- Transplant Institute, NYU Langone Health, New York, NY, USA
| | - David M Feldman
- Department of Medicine, Division of Gastroenterology & Hepatology - NYU Langone Health, New York, NY, USA
| | - James S Park
- Department of Medicine, Division of Gastroenterology & Hepatology - NYU Langone Health, New York, NY, USA
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2
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Thornhill JP, Cromarty B, Gaddie J, Mushunje S, Ferrand RA. Two-drug antiretroviral regimens for HIV. BMJ 2023; 382:e071079. [PMID: 37657789 DOI: 10.1136/bmj-2022-071079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Affiliation(s)
- John P Thornhill
- Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, UK
- Barts Health NHS Trust, London, UK
| | - Ben Cromarty
- UK Community Advisory Board (UK-CAB) HIV treatment advocates network
| | | | - Shiellah Mushunje
- UK Community Advisory Board (UK-CAB) HIV treatment advocates network
| | - Rashida A Ferrand
- Clinical Research Department, London School of Hygiene and Tropical Medicine, UK
- Biomedical Research and Training Institute, Harare, Zimbabwe
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4
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Lactic acidosis and hyperlactatemia associated with lamivudine accumulation and sepsis in a kidney transplant recipient-a case report and review of the literature. AIDS Res Ther 2021; 18:56. [PMID: 34481501 PMCID: PMC8418711 DOI: 10.1186/s12981-021-00382-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background We report a case of sudden, lethal metabolic acidosis in a 70-year-old man on long-term nucleoside reverse transcriptase inhibitor (NRTI) -based antiretroviral therapy (ART) who had developed atypical necrotizing fasciitis 1 month after kidney transplantation. Case presentation The HIV infection of the patient was treated for the last four months with an integrase strand inhibitor (dolutegravir 50 mg/d) plus a NRTI backbone including lamivudine (150 mg/d) and abacavir (600 mg/d). In this renal transplant patient we hypothesize that the co-existence of sepsis, renal failure and an accumulation of lamivudine led to the development of fatal metabolic acidosis and hyperlactatemia. Although lamivudine is only rarely associated with hyperlactatemia, there is evidence that overdose may be a risk factor for developing it. In our patient the lamivudine concentration two days after stopping and during hemodiafiltration was more than 50 times higher than therapeutic target trough concentrations. Likely reasons for this were renal impairment and concurrent treatment with trimethoprim, known to inhibit the renal elimination of lamivudine. Conclusions NRTIs could trigger the development of hyperlactatemia in septic patients. The use of NRTI sparing regimens might be considered in the presence of this critical condition.
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Pillaye JN, Marakalala MJ, Khumalo N, Spearman W, Ndlovu H. Mechanistic insights into antiretroviral drug-induced liver injury. Pharmacol Res Perspect 2021; 8:e00598. [PMID: 32643320 PMCID: PMC7344109 DOI: 10.1002/prp2.598] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022] Open
Abstract
All classes of antiretroviral therapy (ART) have been implicated to induce adverse drug reactions such drug-induced liver injury (DILI) and immune-mediated adverse reactions in Human Immunodeficiency Virus (HIV) infected individuals. Patients that develop adverse drug reactions tend to have prolonged stays in hospital and may require to change to alternative regimens if reactions persist upon rechallenge or if rechallenge is contraindicated due to severity of the adverse reaction. Diagnosis of DILI remains a huge obstacle that delays timely interventions, since it is still based largely on exclusion of other causes. There is an urgent need to develop robust diagnostic and predictive biomarkers that could be used alongside the available tools (biopsy, imaging, and serological tests for liver enzymes) to give a specific diagnosis of DILI. Crucial to this is also achieving consensus in the definition of DILI so that robust studies can be undertaken. Importantly, it is crucial that we gain deeper insights into the mechanism of DILI so that patients can receive appropriate management. In general, it has been demonstrated that the mechanism of ART-induced liver injury is driven by four main mechanisms: mitochondrial toxicity, metabolic host-mediated injury, immune reconstitution, and hypersensitivity reactions. The focus of this review is to discuss the type and phenotypes of DILI that are caused by the first line ART regimens. Furthermore, we will summarize recent studies that have elucidated the cellular and molecular mechanisms of DILI both in vivo and in vitro.
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Affiliation(s)
- Jamie N Pillaye
- Division of Chemical and System Biology, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mohlopheni J Marakalala
- Africa Health Research Institute, Durban, KwaZulu Natal, South Africa.,Division of Infection and Immunity, University College London, London, UK
| | - Nonhlanhla Khumalo
- Hair and Skin Research Lab, Division of Dermatology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Wendy Spearman
- Division of Hepatology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Hlumani Ndlovu
- Division of Chemical and System Biology, Department of Integrative Biomedical Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Abstract
Advances in perinatal HIV management have averted a significant number of infections in neonates and have made the possibility of elimination of mother-to-child transmission a reality; however, significant gaps in implementation of early testing programs as well as the expansion of therapeutic strategies to neonates are hindering prevention efforts and access to safer, more effective and easier to administer treatment. This article provides insights on the current state of perinatal HIV, recent advances, and future needs.
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Affiliation(s)
- Andres F Camacho-Gonzalez
- Division of Pediatric Infectious Diseases, Children's Healthcare of Atlanta, Emory University School of Medicine, 2015 Uppergate Drive, Suite 500, Atlanta, GA 30322, USA.
| | - Paul Palumbo
- Section of Infectious Diseases and International Health, Geisel School of Medicine at Dartmouth, 1 Medical Center Drive, Lebanon, NH 03756, USA
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Vlachakis D, Papakonstantinou E, Mitsis T, Pierouli K, Diakou I, Chrousos G, Bacopoulou F. Molecular mechanisms of the novel coronavirus SARS-CoV-2 and potential anti-COVID19 pharmacological targets since the outbreak of the pandemic. Food Chem Toxicol 2020; 146:111805. [PMID: 33038452 PMCID: PMC7543766 DOI: 10.1016/j.fct.2020.111805] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 12/26/2022]
Abstract
The novel coronavirus SARS-CoV-2 has emerged as a severe threat against public health and global economies. COVID-19, the disease caused by this virus, is highly contagious and has led to an ongoing pandemic. SARS-CoV-2 affects, mainly, the respiratory system, with most severe cases primarily showcasing acute respiratory distress syndrome. Currently, no targeted therapy exists, and since the number of infections and death toll keeps rising, it has become a necessity to study possible therapeutic targets. Antiviral drugs can target various stages of the viral infection, and in the case of SARS-CoV-2, both structural and non-structural proteins have been proposed as potential drug targets. This review focuses on the most researched SARS-CoV-2 proteins, their structure, function, and possible therapeutic approaches.
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Affiliation(s)
- Dimitrios Vlachakis
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 75 Iera Odos, Athens, 11855, Greece; University Research Institute of Maternal and Child Health & Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 8 Levadias Street, Athens, 11527, Greece; Lab of Molecular Endocrinology, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, 4 Soranou Ephessiou Street, Athens, 11527, Greece; Department of Informatics, Faculty of Natural and Mathematical Sciences, King's College London, Strand, London WC2R 2LS, UK
| | - Eleni Papakonstantinou
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 75 Iera Odos, Athens, 11855, Greece
| | - Thanasis Mitsis
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 75 Iera Odos, Athens, 11855, Greece
| | - Katerina Pierouli
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 75 Iera Odos, Athens, 11855, Greece
| | - Io Diakou
- Laboratory of Genetics, Department of Biotechnology, School of Applied Biology and Biotechnology, Agricultural University of Athens, 75 Iera Odos, Athens, 11855, Greece
| | - George Chrousos
- University Research Institute of Maternal and Child Health & Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 8 Levadias Street, Athens, 11527, Greece; Lab of Molecular Endocrinology, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, 4 Soranou Ephessiou Street, Athens, 11527, Greece
| | - Flora Bacopoulou
- University Research Institute of Maternal and Child Health & Precision Medicine, and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital, 8 Levadias Street, Athens, 11527, Greece.
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8
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Chary MA, Barbuto AF, Izadmehr S, Hayes BD, Burns MM. COVID-19: Therapeutics and Their Toxicities. J Med Toxicol 2020; 16:284-294. [PMID: 32356252 PMCID: PMC7192319 DOI: 10.1007/s13181-020-00777-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 02/07/2023] Open
Abstract
SARS-CoV-2 is a novel coronavirus that emerged in 2019 and is causing the COVID-19 pandemic. There is no current standard of care. Clinicians need to be mindful of the toxicity of a wide variety of possibly unfamiliar substances being tested or repurposed to treat COVID-19. The United States Food and Drug Administration (FDA) has provided emergency authorization for the use of chloroquine and hydroxychloroquine. These two medications may precipitate ventricular dysrhythmias, necessitating cardiac and electrolyte monitoring, and in severe cases, treatment with epinephrine and high-doses of diazepam. Recombinant protein therapeutics may cause serum sickness or immune complex deposition. Nucleic acid vaccines may introduce mutations into the human genome. ACE inhibitors and ibuprofen have been suggested to exacerbate the pathogenesis of COVID-19. Here, we review the use, mechanism of action, and toxicity of proposed COVID-19 therapeutics.
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Affiliation(s)
- Michael A Chary
- Division of Emergency Medicine, Harvard Medical Toxicology Fellowship, Boston Children's Hospital, Boston, MA, USA.
- Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA, USA.
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Alexander F Barbuto
- Division of Emergency Medicine, Harvard Medical Toxicology Fellowship, Boston Children's Hospital, Boston, MA, USA
- Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sudeh Izadmehr
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan D Hayes
- Department of Pharmacy, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michele M Burns
- Division of Emergency Medicine, Harvard Medical Toxicology Fellowship, Boston Children's Hospital, Boston, MA, USA
- Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA, USA
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9
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Kamel KS, Oh MS, Halperin ML. L-lactic acidosis: pathophysiology, classification, and causes; emphasis on biochemical and metabolic basis. Kidney Int 2020; 97:75-88. [DOI: 10.1016/j.kint.2019.08.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/01/2019] [Accepted: 08/20/2019] [Indexed: 11/30/2022]
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Abstract
Idiosyncratic (unpredictable) drug-induced liver injury is one of the most challenging liver disorders faced by hepatologists, because of the myriad of drugs used in clinical practice, available herbs and dietary supplements with hepatotoxic potential, the ability of the condition to present with a variety of clinical and pathological phenotypes and the current absence of specific biomarkers. This makes the diagnosis of drug-induced liver injury an uncertain process, requiring a high degree of awareness of the condition and the careful exclusion of alternative aetiologies of liver disease. Idiosyncratic hepatotoxicity can be severe, leading to a particularly serious variety of acute liver failure for which no effective therapy has yet been developed. These Clinical Practice Guidelines summarize the available evidence on risk factors, diagnosis, management and risk minimization strategies for drug-induced liver jury.
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11
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Pasquau J, Hidalgo-Tenorio C, Montes ML, Romero-Palacios A, Vergas J, Sanjoaquín I, Hernández-Quero J, Aguirrebengoa K, Orihuela F, Imaz A, Ríos-Villegas MJ, Flores J, Fariñas MC, Vázquez P, Galindo MJ, García-Mercé I, Lozano F, de los Santos I, de Jesus SE, García-Vallecillos C. High quality of life, treatment tolerability, safety and efficacy in HIV patients switching from triple therapy to lopinavir/ritonavir monotherapy: A randomized clinical trial. PLoS One 2018; 13:e0195068. [PMID: 29649309 PMCID: PMC5896909 DOI: 10.1371/journal.pone.0195068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/15/2018] [Indexed: 01/03/2023] Open
Abstract
Trial design The QoLKAMON study evaluated quality of life, efficacy and treatment safety in HIV patients receiving lopinavir/ritonavir in monotherapy (MT) versus continuing combined antiretroviral triple treatment with a boosted protease inhibitor (TT). Methods This was a 24-week, open-label, multicentre study in virologically-suppressed HIV-infected participants (N = 225) with a 2:1 randomization: 146 patients who switched to MT were compared with 79 patients who remained on a TT regimen. The primary endpoint was change in patient-reported outcomes in quality of life as measured by the MOS-HIV and EQ-5D questionnaires. Secondary endpoints included treatment adherence, patient satisfaction, incidence of adverse events and differences in plasma HIV-1 RNA viral load (VL) and CD4 cell counts. Results Baseline quality of life, measured with the MOS-HIV score, was very good (overall score of 83 ± 10.5 in the MT arm and 82.3 ± 11.3 in the TT arm) and suffered no change during the study in any of the arms (at week 24, 83.5 ± 12.2 in MT arm and 81.9 ± 12.7 in TT arm), without statistically significant differences when compared. In regards to adherence to therapy and patient satisfaction, some aspects (number of doses forgotten in the last week and satisfaction of treatment measured with the CESTA score, dimension 1) improved significantly with MT. There were also no differences in the incidence and severity of adverse events, even though 22.8% of those in the MT arm switched their treatment when they were included in the study. Moreover, there was also no significant difference between the immunological and virological evolution of MT and TT. In the MT arm, the VL was always undetectable in 83% of patients (vs 90.7% in the TT arm) and there were only 6.7% of virological failures with VL > 50 copies/mL (vs 2.3% in the TT arm), without resistance mutations and with resuppression of VL after switching back to TT. Conclusions In a new clinical trial, monotherapy as a treatment simplification strategy in HIV-1 infected patients with sustained viral suppression has demonstrated quality of life, safety and efficacy profiles comparable to those of conventional triple therapy regimens.
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Affiliation(s)
- Juan Pasquau
- Hospital Universitario Virgen de las Nieves, Infectious Diseases, Granada, Spain
- * E-mail:
| | | | - María Luisa Montes
- Hospital Universitario de La Paz, Internal Medicine HIV Unit, Madrid, Spain
| | | | - Jorge Vergas
- Hospital Clínico San Carlos, Infectious Diseases, Granada, Spain
| | - Isabel Sanjoaquín
- Hospital Clínico Universitario Lozano Blesa, Infectious Diseases, Zaragoza, Spain
| | | | | | - Francisco Orihuela
- Hospital Regional Universitario de Málaga, Infectious Diseases, Málaga, Spain
| | - Arkaitz Imaz
- Hospital Universitario de Bellvitge, Infectious Diseases, Barcelona, Spain
| | - María José Ríos-Villegas
- Hospital Universitario Virgen Macarena, Infectious Diseases and Clinical Microbiology, Seville, Spain
| | - Juan Flores
- Hospital Arnau de Vilanova, Infectious Diseases, Valencia, Spain
| | - María Carmen Fariñas
- Hospital Universitario Marqués de Valdecilla, Infectious Diseases, Santander, Spain
| | - Pilar Vázquez
- Hospital Universitario Juan Canalejo, Infectious Diseases, La Coruña, Spain
| | - María José Galindo
- Hospital Clínico Universitario de Valencia, Infectious Diseases, Valencia, Spain
| | | | - Fernando Lozano
- Hospital Universitario Nuestra Señora de Valme, Infectious Diseases, Seville, Spain
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Duplanty AA, Siggins RW, Allerton T, Simon L, Molina PE. Myoblast mitochondrial respiration is decreased in chronic binge alcohol administered simian immunodeficiency virus-infected antiretroviral-treated rhesus macaques. Physiol Rep 2018; 6:e13625. [PMID: 29504290 PMCID: PMC5835494 DOI: 10.14814/phy2.13625] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 12/29/2022] Open
Abstract
Work from our group demonstrated that chronic binge alcohol (CBA)-induces mitochondrial gene dysregulation at end-stage disease of simian immunodeficiency virus (SIV) infection in antiretroviral therapy (ART) naïve rhesus macaques. Alterations in gene expression can disrupt mitochondrial homeostasis and in turn contribute to the risk of metabolic comorbidities characterized by loss of skeletal muscle (SKM) functional mass that are associated with CBA, human immunodeficiency virus (HIV) infection, and prolonged ART. The aim of this study was to examine the interaction of CBA and ART on SKM fiber oxidative capacity and myoblast mitochondrial respiration in asymptomatic SIV-infected macaques. SKM biopsies were obtained and myoblasts isolated at baseline and 11 months post-SIV infection from CBA/SIV/ART+ and from sucrose (SUC)-treated SIV-infected (SUC/SIV/ART+) macaques. CBA and ART decreased succinate dehydrogenase (SDH) activity in type 1 and type 2b fibers as determined by immunohistochemistry. Myoblasts isolated from CBA/SIV/ART+ macaques showed decreased maximal oxygen consumption rate (OCR) compared to myoblasts from control macaques. Maximal OCR was significantly increased in control myoblasts following incubation with formoterol, a beta adrenergic agonist, and this was associated with increased PGC-1α expression and mtDNA quantity. Additionally, formoterol treatment of myoblasts isolated from CBA/SIV/ART+ macaques partially restored maximal OCR to levels not significantly different from control. These results show that CBA in combination with ART impairs myoblast mitochondrial homeostasis in SIV-infected macaques. Moreover, our findings suggest that adrenergic agonists can potentially ameliorate mitochondrial dysfunction. Future studies will elucidate whether physical exercise in HIV patients with alcohol use disorder can improve mitochondrial health.
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Affiliation(s)
- Anthony A. Duplanty
- Department of PhysiologyComprehensive Alcohol Research Center, Alcohol and Drug Abuse Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLouisiana
| | - Robert W. Siggins
- Department of PhysiologyComprehensive Alcohol Research Center, Alcohol and Drug Abuse Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLouisiana
| | - Timothy Allerton
- Department of PhysiologyComprehensive Alcohol Research Center, Alcohol and Drug Abuse Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLouisiana
| | - Liz Simon
- Department of PhysiologyComprehensive Alcohol Research Center, Alcohol and Drug Abuse Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLouisiana
| | - Patricia E. Molina
- Department of PhysiologyComprehensive Alcohol Research Center, Alcohol and Drug Abuse Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLouisiana
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Kumar R, Agrawal S. Rapid Onset of Fatal Lactic Acidosis Complicating Tenofovir Therapy in a Diabetic Patient with Cirrhosis: A Cautionary Tale. J Clin Exp Hepatol 2017; 7:80-81. [PMID: 28348477 PMCID: PMC5357697 DOI: 10.1016/j.jceh.2016.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Ramesh Kumar
- Address for correspondence: Ramesh Kumar, Gastroenterology, Institute of Gastrosciences, Medical Divisions, Paras Hai Medical Research Institute, Patna, Bihar, India.Gastroenterology, Institute of Gastrosciences, Medical Divisions, Paras Hai Medical Research InstitutePatnaBiharIndia
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14
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Successful Treatment of Mitochondrial Toxicity in an HIV-Positive Patient After Liver Transplantation. Transplant Proc 2016; 47:2771-4. [PMID: 26680091 DOI: 10.1016/j.transproceed.2015.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 10/01/2015] [Indexed: 11/20/2022]
Abstract
Liver transplantation in patients infected with the human immunodeficiency virus (HIV) has been increasingly performed with reasonable outcomes; however, medical management of both immunosuppression and antiretroviral therapy can be challenging owing to drug toxicities and interactions. Nucleoside reverse transcriptase inhibitors (NRTIs), a common backbone of highly active antiretroviral therapy (HAART), were the first class of effective antiretroviral drugs developed. NRTIs are commonly used for posttransplant HAART therapy and have a rare but fatal complication of mitochondrial toxicity, manifesting as severe lactic acidosis, hepatic steatosis, and lipoatrophy. Herein, we have reported on the first known successful treatment of severe mitochondrial toxicity secondary to NRTIs in an HIV-infected transplant recipient.
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Abstract
Metabolic acidosis could emerge from diseases disrupting acid-base equilibrium or from drugs that induce similar derangements. Occurrences are usually accompanied by comorbid conditions of drug-induced metabolic acidosis, and clinical outcomes may range from mild to fatal. It is imperative that clinicians not only are fully aware of the list of drugs that may lead to metabolic acidosis but also understand the underlying pathogenic mechanisms. In this review, we categorized drug-induced metabolic acidosis in terms of pathophysiological mechanisms, as well as individual drugs’ characteristics.
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Affiliation(s)
- Amy Quynh Trang Pham
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Baylor Family Medicine Residency at Garland, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Li Hao Richie Xu
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Departments of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA; Department of Physiology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 75390-8885, USA
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Hashim H, Sahari NS, Sazlly Lim SM, Hoo FK. Fatal Tenofovir-Associateacd Lactic Acidosis: A Case Report. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e19546. [PMID: 26568856 PMCID: PMC4636755 DOI: 10.5812/ircmj.19546] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 09/03/2014] [Accepted: 03/31/2015] [Indexed: 11/16/2022]
Abstract
Introduction: The introduction of highly active antiretroviral therapy (HAART), in 1996, has resulted in marked reductions in the rate of illness and death, due to HIV infection. The HAART has transformed HIV infection into a manageable chronic disease. However, although many regimens lower plasma viral load, to below the limit of detection, in most patients, maintaining viral load suppression remains challenging, because of adverse effects and toxicity in the long term, which can lead to non-adherence, virologic failure and drug resistance. Although rare, lactic acidosis often develops fatal complications, as reported in several human immunodeficiency virus infected patients treated with nucleoside reverse transcriptase inhibitors (NRTIs). The purpose of this paper is to report a case of tenofovir induced lactic acidosis and review the literature. Case Presentation: A 52-year-old Malay gentleman, with hepatitis C virus and HIV infection was admitted to the intensive care unit for severe lactic acidosis, with concurrent Escherichia coli bacteremia with multiorgan dysfunction. The patient was started on highly active antiretroviral therapy, which included tenofovir, 5 weeks before presentation. Antimicrobial therapy, continuous veno-venous hemofiltration, and other supportive treatments were instituted. However, the patient eventually succumbed to his illness. Conclusions: It is essential for clinicians to be able to recognize the signs and symptoms of lactic acidosis in NRTIs treated HIV patients, as an early diagnosis is important to institute treatment.
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Affiliation(s)
- Hasriza Hashim
- Department of Medicine, Hospital Putrajaya, Putrajaya, Malaysia
| | - Narisa Sulaiman Sahari
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Sazlyna Mohd Sazlly Lim
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
- Corresponding Author: Sazlyna Mohd Sazlly Lim, Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia. Tel: +60-389472568, Fax: +60-389472759, E-mail:
| | - Fan Kee Hoo
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
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Tan D, Walmsley S, Shen S, Raboud J. Mild to Moderate Symptoms Do Not Correlate with Lactate Levels in HIV-Positive Patients on Nucleoside Reverse Transcriptase Inhibitors. HIV CLINICAL TRIALS 2015; 7:107-15. [PMID: 16880167 DOI: 10.1310/95ve-a6kj-wrq0-1f8y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Nucleoside reverse transcriptase inhibitors (NRTIs) are associated with mitochondrial toxicities ranging from asymptomatic hyperlactatemia to fatal lactic acidosis. It is uncertain whether mild clinical symptoms predict hyperlactatemia and the need to consider changes in antiretroviral therapy. This cross-sectional study evaluated whether an association exists between mild symptoms and lactate levels. METHOD HIV-positive patients on NRTIs attending routine clinic visits were surveyed about symptoms associated with hyperlactatemia. Symptom severity was quantified using Likert scales, and the sum was converted into a symptom score ranging from 0 to 30. Tourniquet-free blood specimens were collected simultaneously to measure serum lactate. Symptom scores were compared between patients with normal and elevated lactates. RESULTS 284 individuals were included. The most common NRTIs used included lamivudine (79%), zidovudine (50%), abacavir (39%), and stavudine (24%). Twenty-two patients (8%) had increased lactates (mean = 2.7 mmol/L; range, 2.1-4.5 mmol/L), while 262 patients (92%) had normal lactates (mean = 1.2 mmol/L, range, 0.1-2.0 mmol/L). Median symptom scores were similar between groups (3 vs. 2, p = .23). Spearman's correlation coefficient for lactate and symptom score was 0.07 (p = .22). CONCLUSIONS Mild symptoms did not correlate with lactate levels, and symptoms alone should not trigger clinicians to measure serum lactates and stop NRTIs if the levels are elevated.
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Affiliation(s)
- Darrell Tan
- Division of Infectious Diseases, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4.
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Abstract
There are an estimated 40 million HIV infected individuals worldwide, with chronic liver disease being the 2nd leading cause of mortality in this population. Elevated liver functions are commonly noted in HIV patients and the etiologies are varied. Viral hepatitis B and C, fatty liver and drug induced liver injury are more common. Treatment options for viral hepatitis C are rapidly evolving and are promising, but treatments are limited for the other conditions and is primarily supportive. Opportunistic infections of the liver are now uncommon. Irrespective of etiology, management requires referral to specialized centers and with due diligence mortality can be reduced.
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Margolis AM, Heverling H, Pham PA, Stolbach A. A review of the toxicity of HIV medications. J Med Toxicol 2014; 10:26-39. [PMID: 23963694 DOI: 10.1007/s13181-013-0325-8] [Citation(s) in RCA: 224] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antiretroviral therapy has changed human immunodeficiency virus (HIV) infection from a near-certainly fatal illness to one that can be managed chronically. More patients are taking antiretroviral drugs (ARVs) for longer periods of time, which naturally results in more observed toxicity. Overdose with ARVs is not commonly reported. The most serious overdose outcomes have been reported in neonates who were inadvertently administered supratherapeutic doses of HIV prophylaxis medications. Typical ARV regimens include a "backbone" of two nucleoside reverse transcriptase inhibitors (NRTI) and a "base" of either a protease inhibitor (PI) or nonnucleoside reverse transcriptase inhibitor. New classes of drugs called entry inhibitors and integrase inhibitors have also emerged. Older NRTIs were associated with mitochondrial toxicity, but this is less common in the newer drugs, emtricitabine, lamivudine, and tenofovir. Mitochondrial toxicity results from NRTI inhibition of a mitochondrial DNA polymerase. Mitochondrial toxicity manifests as myopathy, neuropathy, hepatic failure, and lactic acidosis. Routine lactate assessment in asymptomatic patients is not indicated. Lactate concentration should be obtained in patients taking NRTIs who have fatigue, nausea, vomiting, or vague abdominal pain. Mitochondrial toxicity can be fatal and is treated by supportive care and discontinuing NRTIs. Metabolic cofactors like thiamine, carnitine, and riboflavin may be helpful in managing mitochondrial toxicity. Lipodystrophy describes changes in fat distribution and lipid metabolism that have been attributed to both PIs and NRTIs. Lipodystrophy consists of loss of fat around the face (lipoatrophy), increase in truncal fat, and hypertriglyceridemia. There is no specific treatment of lipodystrophy. Clinicians should be able to recognize effects of chronic toxicity of ARVs, especially mitochondrial toxicity.
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Affiliation(s)
- Asa M Margolis
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, New York, NY, USA
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[Consensus Statement by GeSIDA/National AIDS Plan Secretariat on antiretroviral treatment in adults infected by the human immunodeficiency virus (Updated January 2013)]. Enferm Infecc Microbiol Clin 2013; 31:602.e1-602.e98. [PMID: 24161378 DOI: 10.1016/j.eimc.2013.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 04/08/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients. METHODS To formulate these recommendations a panel composed of members of the GeSIDA/National AIDS Plan Secretariat (Grupo de Estudio de Sida and the Secretaría del Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations and the evidence which support them are based on a modification of the criteria of Infectious Diseases Society of America. RESULTS cART is recommended in patients with symptoms of HIV infection, in pregnant women, in serodiscordant couples with high risk of transmission, in hepatitisB co-infection requiring treatment, and in HIV nephropathy. cART is recommended in asymptomatic patients if CD4 is <500cells/μl. If CD4 are >500cells/μl cART should be considered in the case of chronic hepatitisC, cirrhosis, high cardiovascular risk, plasma viral load >100.000 copies/ml, proportion of CD4 cells <14%, neurocognitive deficits, and in people aged >55years. The objective of cART is to achieve an undetectable viral load. The first cART should include 2 reverse transcriptase inhibitors (RTI) nucleoside analogs and a third drug (a non-analog RTI, a ritonavir boosted protease inhibitor, or an integrase inhibitor). The panel has consensually selected some drug combinations, for the first cART and specific criteria for cART in acute HIV infection, in tuberculosis and other HIV related opportunistic infections, for the women and in pregnancy, in hepatitisB or C co-infection, in HIV-2 infection, and in post-exposure prophylaxis. CONCLUSIONS These new guidelines update previous recommendations related to first cART (when to begin and what drugs should be used), how to monitor, and what to do in case of viral failure or adverse drug reactions. cART specific criteria in comorbid patients and special situations are similarly updated.
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Kovari H, Sabin CA, Ledergerber B, Ryom L, Worm SW, Smith C, Phillips A, Reiss P, Fontas E, Petoumenos K, De Wit S, Morlat P, Lundgren JD, Weber R. Antiretroviral drug-related liver mortality among HIV-positive persons in the absence of hepatitis B or C virus coinfection: the data collection on adverse events of anti-HIV drugs study. Clin Infect Dis 2012; 56:870-9. [PMID: 23090925 DOI: 10.1093/cid/cis919] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Liver diseases are the leading causes of death in human immunodeficiency virus (HIV)-positive persons since the widespread use of combination antiretroviral treatment (cART). Most of these deaths are due to hepatitis C (HCV) or B (HBV) virus coinfections. Little is known about other causes. Prolonged exposure to some antiretroviral drugs might increase hepatic mortality. METHODS All patients in the Data Collection on Adverse Events of Anti-HIV Drugs study without HCV or HBV coinfection were prospectively followed from date of entry until death or last follow-up. In patients with liver-related death, clinical charts were reviewed using a structured questionnaire. RESULTS We followed 22 910 participants without hepatitis virus coinfection for 114 478 person-years. There were 12 liver-related deaths (incidence, 0.10/1000 person-years); 7 due to severe alcohol use and 5 due to established ART-related toxicity. The rate of ART-related deaths in treatment-experienced persons was 0.04/1000 person-years (95% confidence interval, .01, .10). CONCLUSIONS We found a low incidence of liver-related deaths in HIV-infected persons without HCV or HBV coinfection. Liver-related mortality because of ART-related toxicity was rare.
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Affiliation(s)
- Helen Kovari
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland.
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Monotherapy with atazanavir as a simplification strategy: results from an observational study. J Acquir Immune Defic Syndr 2012; 60:e101-3. [PMID: 22728751 DOI: 10.1097/qai.0b013e318258bf3c] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wester CW, Eden SK, Shepherd BE, Bussmann H, Novitsky V, Samuels DC, Hendrickson SL, Winkler CA, O'Brien SJ, Essex M, D'Aquila RT, deGruttola V, Marlink RG. 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; 28:759-65. [PMID: 22540188 DOI: 10.1089/aid.2011.0303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Nucleoside analogue reverse transcriptase inhibitors are an integral component of combination antiretroviral treatment regimens. However, their ability to inhibit polymerase-γ has been associated with several mitochondrial toxicities, including potentially life-threatening lactic acidosis. A total of 650 antiretroviral-naive adults (69% female) initiated combination antiretroviral therapy (cART) and were intensively screened for toxicities including lactic acidosis as part of a 3-year clinical trial in Botswana. Patients were categorized as no lactic acidosis symptoms, minor symptoms but lactate <4.4 mmol/liter, and symptoms with lactate ≥ 4.4 mmol/liter [moderate to severe symptomatic hyperlactatemia (SH) or lactic acidosis (LA)]. Of 650 participants 111 (17.1%) developed symptoms and/or laboratory results suggestive of lactic acidosis and had a serum lactate drawn; 97 (87.4%) of these were female. There were 20 events, 13 having SH and 7 with LA; all 20 (100%) were female (p<0.001). Cox proportional hazard analysis limited to the 451 females revealed that having a higher baseline BMI was predictive for the development of SH/LA [aHR=1.17 per one-unit increase (1.08-1.25), p<0.0001]. Ordered logistic regression performed among all 650 patients revealed that having a lower baseline hemoglobin [aOR=1.28 per one-unit decrease (1.1-1.49), p=0.002] and being randomized to d4T/3TC-based cART [aOR=1.76 relative to ZDV/3TC (1.03-3.01), p=0.04] were predictive of the symptoms and/or the development of SH/LA. cART-treated women in sub-Saharan Africa, especially those having higher body mass indices, should receive additional monitoring for SH/LA. Women presently receiving d4T/3TC-based cART in such settings also warrant more intensive monitoring.
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Affiliation(s)
- C. William Wester
- Harvard School of Public Health, Boston, Massachusetts
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee
| | | | | | - Hermann Bussmann
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
| | - Vladimir Novitsky
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
| | - David C. Samuels
- Vanderbilt University School of Medicine, Center for Human Genetics Research, Department of Molecular Physiology and Biophysics, Nashville, Tennessee
| | - Sher L. Hendrickson
- Laboratory of Genomic Diversity, SAIC-Frederick Inc., National Cancer Institute, Frederick, Maryland
| | - Cheryl A. Winkler
- Laboratory of Genomic Diversity, SAIC-Frederick Inc., National Cancer Institute, Frederick, Maryland
| | - Stephen J. O'Brien
- Laboratory of Genomic Diversity, SAIC-Frederick Inc., National Cancer Institute, Frederick, Maryland
| | - Max Essex
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
| | | | | | - Richard G. Marlink
- Harvard School of Public Health, Boston, Massachusetts
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), Gaborone, Botswana
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[Consensus document of Gesida and Spanish Secretariat for the National Plan on AIDS (SPNS) regarding combined antiretroviral treatment in adults infected by the human immunodeficiency virus (January 2012)]. Enferm Infecc Microbiol Clin 2012; 30:e1-89. [PMID: 22633764 DOI: 10.1016/j.eimc.2012.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 03/19/2012] [Indexed: 11/20/2022]
Abstract
This consensus document has been prepared by a panel consisting of members of the AIDS Study Group (Gesida) and the Spanish Secretariat for the National Plan on AIDS (SPNS) after reviewing the efficacy and safety results of clinical trials, cohort and pharmacokinetic studies published in medical journals, or presented in medical scientific meetings. Gesida has prepared an objective and structured method to prioritise combined antiretroviral treatment (cART) in naïve patients. Recommendations strength (A, B, C) and the evidence which supports them (I, II, III) are based on a modification of the Infectious Diseases Society of America criteria. The current antiretroviral treatment (ART) of choice for chronic HIV infection is the combination of three drugs. ART is recommended in patients with symptomatic HIV infection, in pregnancy, in serodiscordant couples with high transmission risk, hepatitis B fulfilling treatment criteria, and HIV nephropathy. Guidelines on ART treatment in patients with concurrent diagnosis of HIV infection and an opportunistic type C infection are included. In asymptomatic patients ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts <350 cells/μL; 2) when CD4 counts are between 350 and 500 cells/μL, therapy will be recommended and only delayed if patient is reluctant to take it, the CD4 are stabilised, and the plasma viral load is low; 3) therapy could be deferred when CD4 counts are above 500 cells/μL, but should be considered in cases of cirrhosis, chronic hepatitis C, high cardiovascular risk, plasma viral load >10(5) copies/mL, proportion of CD4 cells <14%, and in people aged >55 years. ART should include 2 reverse transcriptase inhibitors nucleoside analogues and a third drug (non-analogue reverse transcriptase inhibitor, ritonavir boosted protease inhibitor or integrase inhibitor). The panel has consensually selected and given priority to using the Gesida score for some drug combinations, some of them co-formulated. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures, but an undetectable viral load may be possible nowadays. Adverse events are a fading problem of ART. Guidelines in acute HIV infection, in women, in pregnancy, and to prevent mother-to-child transmission and pre- and post-exposition prophylaxis are commented upon. Management of hepatitis B or C co-infection, other co-morbidities, and the characteristics of ART in HIV-2 infection are included.
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Leung L, Wilson D, Manini AF. Fatal toxicity from symptomatic hyperlactataemia: a retrospective cohort study of factors implicated with long-term nucleoside reverse transcriptase inhibitor use in a South African hospital. Drug Saf 2011; 34:521-7. [PMID: 21488705 DOI: 10.2165/11588240-000000000-00000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND In many Sub-Saharan African countries, first-line therapy for HIV may include a nucleoside reverse transcriptase inhibitor (NRTI). Long-term NRTI use is associated with symptomatic hyperlactataemia due to inhibition of mitochondrial DNA polymerase γ, a potentially fatal complication. OBJECTIVE The purpose of the study was to evaluate the factors associated with inhospital fatality for HIV inpatients prescribed NRTIs long term who presented with symptomatic hyperlactataemia. METHODS We performed a retrospective cohort study at a 900-bed university hospital in South Africa over 4 years (2005-2008). We included HIV inpatients prescribed NRTIs long term who presented with symptomatic hyperlactataemia (long-term NRTI use; lactate >4.0 mmol/L; absence of infectious source; symptoms requiring admission). Data included demographics, medical history, NRTI duration, blood pressure, symptom duration and relevant laboratory data. RESULTS Of 79 patients who met inclusion criteria (mean age 38.2 ± 10.5 years, 97% female) there were 46 fatalities (58%). Factors significantly associated with fatality were presence of diabetes mellitus (p = 0.04), lactate ≥10 mmol/L (p = 0.003), pH <7.2 (p = 0.002), creatinine ≥200 μmol/L (p = 0.03) and altered mental status (p = 0.03). CONCLUSIONS In this study, NRTI-related symptomatic hyperlactataemia occurred predominantly in females. Mortality was associated with severely elevated lactate (≥10 mmol/L), the degree of acidosis, elevated creatinine, history of diabetes and altered mental status on presentation.
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Affiliation(s)
- Liza Leung
- Department of Emergency Medicine, Mt Sinai School of Medicine, New York, New York 10029, USA.
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Livshits Z, Lee S, Hoffman RS, Nelson LS, Esteban-Cruciani N. Zidovudine (AZT) overdose in a healthy newborn receiving postnatal prophylaxis. Clin Toxicol (Phila) 2011; 49:747-9. [PMID: 21867364 DOI: 10.3109/15563650.2011.602081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Pediatric medication dosing and administration, faced with inherent challenges of dose to body weight adjustment and variable delivery vehicles, may lead to inadvertent errors effectively resulting in overdose. Zidovudine (AZT), a nucleoside analog reverse transcriptase inhibitor (NRTI), is a commonly prescribed medication to treat HIV-exposed newborns, with limited overdose data in this patient population. Metabolic acidosis with elevated lactate is the most serious consequence of AZT toxicity in the adult population, associated with mortality. Other significant effects may include neutropenia and hepatic dysfunction. CASE REPORT A 4-day-old male infant who received two inadvertent 10-fold overdoses of AZT while being treated for HIV postnatal prophylaxis. The newborn developed a transient metabolic acidosis with elevated lactate that resolved within 24 h, a small increase in AST, and persistent neutropenia for 5 weeks. The patient's mother cited several key factors leading to the dosing error. DISCUSSION The paucity of AZT overdose data in newborns and infants compels this case report, which reviews the published literature and provides insight into prevention and improvement of pediatric patient safety.
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Affiliation(s)
- Zhanna Livshits
- New York City Poison Control Center, New York, NY 10016, United States.
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Domingo P, Lozano F. Manejo de la toxicidad por fármacos antirretrovirales. Enferm Infecc Microbiol Clin 2011; 29:535-44. [DOI: 10.1016/j.eimc.2010.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 11/29/2010] [Accepted: 12/01/2010] [Indexed: 01/11/2023]
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Cadilla A, Qureshi N, Johnson DC. Pediatric antiretroviral therapy. Expert Rev Anti Infect Ther 2011; 8:1381-402. [PMID: 21133664 DOI: 10.1586/eri.10.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The rate of perinatal HIV transmission has decreased significantly in developed countries. However, worldwide, it remains the main source of HIV infection within the pediatric population. Recent advances as a result of findings from clinical trials, viral resistance testing and the advent of new drugs have increased the options for initial treatment regimens. This article provides an overview of antiretroviral therapy in treatment-naive children, including recent pediatric data and updated guidelines from the NIH. It also provides information on new drugs approved for the pediatric age group, dosage information, drug resistance testing and monitoring suggestions for children and adolescents receiving antiretroviral therapy. Special issues pertaining to adherence, disclosure and contraception are also highlighted.
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Affiliation(s)
- Adriana Cadilla
- University of Chicago, Pritzker School of Medicine, 5841 S. Maryland Avenue, MC6082, Chicago, IL 60637, USA
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Arenas-Pinto A, Weller I, Ekong R, Grant A, Karstaedt A, Reiss P, Telisinghe L, Weber R, Bolhaar M, Bradman N, Ingram C. Common inherited mitochondrial DNA mutations and nucleoside reverse transcriptase inhibitor-induced severe hyperlactataemia in HIV-infected adults: an exploratory study. Antivir Ther 2011; 17:275-82. [DOI: 10.3851/imp1947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2011] [Indexed: 10/15/2022]
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Fatal lactic acidosis in a kidney transplant recipient on combination antiretroviral therapy after initiation of tacrolimus therapy. Case Rep Transplant 2011; 2011:210178. [PMID: 23213600 PMCID: PMC3505952 DOI: 10.1155/2011/210178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 12/20/2011] [Indexed: 12/23/2022] Open
Abstract
In general, kidney transplantation is safe and efficacious in patients receiving treatment for HIV. Although multiple drug interactions between antiviral and immunosuppressive treatments exist, few patients experience serious adverse reactions. We report a case of fatal lactic acidosis in a healthy kidney transplant recipient with stable HIV infection who had previously received treatment for and cleared hepatitis C virus infection. Death occurred less than one month following the initiation of tacrolimus therapy. Based on predicted drug interactions, appropriate tacrolimus dosing was calculated prior to its commencement, yet plasma tacrolimus levels were initially unexpectedly high. The patient subsequently developed lactic acidosis and hepatic steatosis, presumably due to mitochondrial toxicity from the antiretroviral regimen on which he had previously been stable. We suspect CYP2C19*2 (poor metaboliser) genotype status and concomitant treatment with lansoprazole, tacrolimus, and antiretroviral (ARV) medications resulted in hepatic decompensation. This highlights the importance of careful interaction screening for all new drugs administered to patients with HIV who have complex treatment regimens as well as heightened clinical vigilance for unexpected toxicities.
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Arenas-Pinto A, Grant A, Bhaskaran K, Copas A, Carr A, Worm SW, Martinez E, Reiss P, Dunn D, Weber R, Hoy J, Weller I. Risk factors for fatality in HIV-infected patients with dideoxynucleoside-induced severe hyperlactataemia or lactic acidosis. Antivir Ther 2011; 16:219-26. [PMID: 21447871 DOI: 10.3851/imp1739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Lactic acidosis (LA) and severe hyperlactataemia (HL) are infrequent but serious complications of antiretroviral therapy that have been associated with a high fatality rate. METHODS In a multinational retrospective cohort study, LA was defined as arterial blood pH<7.35, bicarbonate <20 mmol/l and lactate above normal, and HL as confirmed blood lactate >5 mmol/l. Logistic regression was used to identify factors associated with fatality. Sensitivity and specificity of different case definitions as predictors of death were compared. RESULTS The overall case-fatality rate was 19/110 (17.3%), but among acidotic patients it was 33% (16/49 cases). There were 10 asymptomatic patients and none of them died as a consequence of the event. The median lactate for fatal, non-fatal and all patients was 8.3 mmol/l (IQR 7.2-13.1), 6.4 mmol/l (IQR 5.4-7.8) and 6.7 mmol/l (IQR 5.5-8.1), respectively. After adjusting for age and current CD4(+) T-cell count, lactate >7 mmol/l (OR 6.27, 95% CI 1.13-34.93), blood bicarbonate <12 mmol/l (OR 10.02 relative to >18 mmol/l, 95% CI 1.33-75.65) and concurrent opportunistic infections (OR 8.69, 95% CI 1.45-52.22) were independently associated with case fatality. Blood lactate >7 mmol/l showed a sensitivity of 84% for fatality with a specificity of 60%, whereas bicarbonate <12 mmol/l showed a better specificity (85%) but a poorer sensitivity (42%). Bicarbonate <18 mmol/l appears to be as good as lactate <7 mmol/l at predicting death (sensitivity 90% and specificity 54%). CONCLUSIONS Our data suggest that blood lactate >7 mmol/l and blood bicarbonate <18 mmol/l appear to predict death and might help clinicians in selecting patients who may benefit from more intense monitoring.
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Viganò A, Cerini C, Pattarino G, Fasan S, Zuccotti GV. Metabolic complications associated with antiretroviral therapy in HIV-infected and HIV-exposed uninfected paediatric patients. Expert Opin Drug Saf 2010; 9:431-45. [PMID: 20078250 DOI: 10.1517/14740330903579991] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD HIV-infection has become a chronic disease in paediatric patients with the potential for long-term survival and exposure to antiretroviral (ARV) therapies for 2 decades longer than HIV-infected adults. On the other hand, the administration of ARV to HIV-infected pregnant women has greatly increased both treatment of HIV infection and prevention of perinatal HIV transmission. Therefore, researches aiming to evaluate the safety of ARV therapies in HIV-infected children as well as in HIV-uninfected infants born to HIV-infected mothers are emerging as a new challenge and urgent priority. AREAS COVERED IN THIS REVIEW The purpose of this review is to describe some of the more concerning metabolic complications associated with ARV in paediatric population: hyperlactataemia (HLA) syndromes, body shape abnormalities, disorders of glucose homeostasis and dyslipidaemia in HIV-infected children and adolescents. Frequency, risk factors, clinical findings, prevention and intervention strategies of the previously described abnormalities are discussed in depth. WHAT THE READER WILL GAIN This review covers our current understanding of HLA syndromes in ARV-exposed uninfected infants born to HIV-infected mothers. TAKE HOME MESSAGE Prevention of these metabolic complications should assume prominence and future researches should address several of the existing treatment gaps.
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Affiliation(s)
- Alessandra Viganò
- Università di Milano, Luigi Sacco Hospital, Department of Pediatrics, Milan, Italy.
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Camacho-Gonzalez AF, Ross AC, Chakraborty R. The clinical care of the HIV-1-infected infant. Clin Perinatol 2010; 37:873-85, xi. [PMID: 21078456 DOI: 10.1016/j.clp.2010.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite well-established strategies to decrease the mother-to-child transmission of HIV-1, new perinatal infections continue to occur globally, reflecting marked disparities in access to health care. Once HIV-1 infection has been established in an infant, the combination of early initiation of antiretroviral therapy and prophylaxis against Pneumocystis jiroveci pneumonia is paramount to reducing disease progression. This article reviews the recommendations and evidence for the treatment of HIV-1-infected infants.
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Affiliation(s)
- Andres F Camacho-Gonzalez
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University, 2015 Uppergate Drive, Suite 500, Atlanta, GA 30322, USA
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Minga A, Lewden C, Dohoun L, Abo Y, Emieme A, Coulibaly A, Salamon R, Eholié S, Anglaret X, Danel C. Short communication: Severe symptomatic hyperlactatemia among HIV type 1-infected adults on antiretroviral therapy in Côte d'Ivoire. AIDS Res Hum Retroviruses 2010; 26:991-5. [PMID: 20707728 DOI: 10.1089/aid.2009.0309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Stavudine is no longer recommended for use in first-line antiretroviral therapy (ART), but it remains in high demand worldwide because it is affordable. We report the clinical presentation and incidence of severe hyperlactatemia (SL) in HIV-infected adults who initiated ART between April 2005 and May 2009 in Côte d'Ivoire, West Africa. In a prospective cohort study at the HIV care center affiliated with the National Centre for Blood Transfusion, we used standardized forms to record baseline and follow-up data. We measured serum lactate levels for all adults on ART who showed signs of hyperlactatemia. SL was defined as serum lactate >2.5 mmol/liter. Overall, 806 adults initiated ART. Among the 591 patients (73%) on stavudine-containing regimens, 394 were women (67%); the median pre-ART CD4 count was 150/mm3 and the median body mass index was 20.9 kg/m2. These patients were followed for a median of 28 months. We detected SL only among patients taking stavudine. The incidence of SL was 0.55/100 person-years (PY) (95% CI 0.47-0.63) overall and 0.85/100 PY among women (95% CI 0.75-0.95). Among the eight patients with SL, 100% lost >9% of body weight before diagnosis, 100% had serum lactate >4 mmol/liter (range 4.2-12.1), 50% had pre-ART BMI >25 kg/m2, and three patients died (38%), accounting for 6.4% of deaths among patients taking stavudine. As long as HIV clinicians continue to use stavudine in sub-Saharan Africa, they should watch out for acute unexplained weight loss in patients taking ART, particularly among women and patients with high pre-ART BMI.
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Affiliation(s)
- Albert Minga
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Charlotte Lewden
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | | | - Yao Abo
- Programme PAC-CI, Abidjan, Côte d'Ivoire
| | | | - Ali Coulibaly
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Abidjan, Côte d'Ivoire
| | - Roger Salamon
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Serge Eholié
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- Service des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d'Ivoire
| | - Xavier Anglaret
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
| | - Christine Danel
- Programme PAC-CI, Abidjan, Côte d'Ivoire
- INSERM, U897, Bordeaux, France
- Université Victor Segalen Bordeaux 2, Bordeaux, France
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Cohn J, Baker B. Obstacles and opportunities to improve antiretroviral regimen access in low-income countries. Curr HIV/AIDS Rep 2010; 7:161-7. [PMID: 20532837 DOI: 10.1007/s11904-010-0053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Increasing evidence suggests that dramatically increasing access to effective and well-tolerated antiretroviral medications is key to reversing the HIV pandemic. Currently used first-line therapies in developing countries have multiple toxicities that cause significant morbidity and mortality. New World Health Organization HIV treatment guidelines support earlier treatment initiation and the use of less toxic first-line therapies. Adoption of these guidelines requires political and financial commitment from multiple stakeholders including country governments and donors. This review summarizes the major adverse effects associated with commonly used ARV regimens in low-income countries and also analyzes some of the barriers and potential solutions that affect the ability of low-income countries to implement the new World Health Organization guidelines.
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Affiliation(s)
- Jennifer Cohn
- Hospital of the University of Pennsylvania, 3400 Spruce Street, 3rd Floor Silverstein Building, Suite D, Philadelphia, PA 19104, USA.
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[AIDS Study Group/Spanish AIDS Plan consensus document on antiretroviral therapy in adults with human immunodeficiency virus infection (updated January 2010)]. Enferm Infecc Microbiol Clin 2010; 28:362.e1-91. [PMID: 20554079 DOI: 10.1016/j.eimc.2010.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 03/14/2010] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This consensus document is an update of antiretroviral therapy recommendations for adult patients with human immunodeficiency virus infection. METHODS To formulate these recommendations a panel made up of members of the Grupo de Estudio de Sida (Gesida, AIDS Study Group) and the Plan Nacional sobre el Sida (PNS, Spanish AIDS Plan) reviewed the advances in the current understanding of the pathophysiology of human immunodeficiency virus (HIV) infection, the efficacy and safety of clinical trials, and cohort and pharmacokinetic studies published in biomedical journals or presented at scientific meetings. Three levels of evidence were defined according to the data source: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not to recommend ART was established in each situation. RESULTS Currently, the treatment of choice for chronic HIV infection is the combination of three drugs of two different classes, including 2 nucleosides or nucleotide analogs (NRTI) plus 1 non-nucleoside (NNRTI) or 1 boosted protease inhibitor (PI/r), but other combinations are possible. Initiation of ART is recommended in patients with symptomatic HIV infection. In asymptomatic patients, initiation of ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts below 350 cells/microl; 2) When CD4 counts are between 350 and 500 cells/microl, therapy should be started in case of cirrhosis, chronic hepatitis C, high cardiovascular risk, HIV nephropathy, HIV viral load above 100,000 copies/ml, proportion of CD4 cells under 14%, and in people aged over 55; 3) Therapy should be deferred when CD4 are above 500 cells/microl, but could be considered if any of previous considerations concurs. Treatment should be initiated in case of hepatitis B requiring treatment and should be considered for reduce sexual transmission. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures but undetectable viral loads maybe possible with the new drugs even in highly drug experienced patients. Genotype studies are useful in these situations. Drug toxicity of ART therapy is losing importance as benefits exceed adverse effects. Criteria for antiretroviral treatment in acute infection, pregnancy and post-exposure prophylaxis are mentioned as well as the management of HIV co-infection with hepatitis B or C. CONCLUSIONS CD4 cells counts, viral load and patient co-morbidities are the most important reference factors to consider when initiating ART in asymptomatic patients. The large number of available drugs, the increased sensitivity of tests to monitor viral load, and the ability to determine viral resistance is leading to a more individualized therapy approach in order to achieve undetectable viral load under any circumstances.
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Abstract
Metabolic acidosis may occasionally develop in the course of treatment with drugs used in everyday clinical practice, as well as with the exposure to certain chemicals. Drug-induced metabolic acidosis, although usually mild, may well be life-threatening, as in cases of lactic acidosis complicating antiretroviral therapy or treatment with biguanides. Therefore, a detailed medical history, with special attention to the recent use of culprit medications, is essential in patients with acid-base derangements. Effective clinical management can be handled through awareness of the adverse effect of certain pharmaceutical compounds on the acid-base status. In this review, we evaluate relevant literature with regard to metabolic acidosis associated with specific drug treatment, and discuss the clinical setting and underlying pathophysiological mechanisms. These mechanisms involve renal inability to excrete the dietary H+ load (including types I and IV renal tubular acidoses), metabolic acidosis owing to increased H+ load (including lactic acidosis, ketoacidosis, ingestion of various substances, administration of hyperalimentation solutions and massive rhabdomyolysis) and metabolic acidosis due to HCO3- loss (including gastrointestinal loss and type II renal tubular acidosis). Determinations of arterial blood gases, the serum anion gap and, in some circumstances, the serum osmolar gap are helpful in delineating the pathogenesis of the acid-base disorder. In all cases of drug-related metabolic acidosis, discontinuation of the culprit medications and avoidance of readministration is advised.
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Affiliation(s)
- George Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
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Abstract
BACKGROUND Lactic acidosis (LA) is common in hospitalized patients and is associated with poor clinical outcomes. There have been major recent advances in our understanding of lactate generation and physiology. However, treatment of LA is an area of controversy and uncertainty, and the use of agents to raise pH is not clearly beneficial. AIM AND METHODS We reviewed animal and human studies on the pathogenesis, impact, and treatment of LA, published in the English language and available through the PubMed/MEDLINE database. Our aim was to clarify the physiology of the generation of LA, its impact on outcomes, and the different treatment modalities available. We also examined relevant data regarding LA induced by medications commonly prescribed by hospitalists: biguanides, nucleoside analog reverse-transcriptase inhibitors (NRTIs), linezolid, and lorazepam. RESULTS/CONCLUSIONS Lactic acid is a marker of tissue ischemia but it also may accumulate without tissue hypoperfusion. In the latter circumstance, lactic acid accumulation may be an adaptive mechanism-a novel possibility quite in contrast to the traditional view of lactic acid as only a marker of tissue ischemia. Studies on the treatment of LA with sodium bicarbonate or other buffers fail to show consistent clinical benefit. Severe acidemia in the setting of LA is a particularly poorly studied area. In the settings of medication-induced LA, optimal treatment, apart from prompt cessation of the offending agent, is still unclear.
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Affiliation(s)
- Jean-Sebastien Rachoin
- Division of Nephrology, Department of Medicine, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey 08103, USA.
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Genetic and Functional Mitochondrial Assessment of HIV-Infected Patients Developing HAART-Related Hyperlactatemia. J Acquir Immune Defic Syndr 2009; 52:443-51. [DOI: 10.1097/qai.0b013e3181bd564c] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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[Lopinavir/ritonavir monotherapy as a simplification strategy in the treatment of HIV-1 infection]. Enferm Infecc Microbiol Clin 2009; 26 Suppl 16:12-20. [PMID: 19572439 DOI: 10.1016/s0213-005x(08)76605-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Simplification of triple antiretroviral therapy to lopinavir/ritonavir (LPV/r) monotherapy in patients with well-controlled viremia for prolonged periods (more than 6 months) without prior failure with a protease inhibitor has been proposed as a strategy that could reduce the toxicity and costs of antiretroviral therapy in the long term while also preserving other therapeutic options. The results of several studies are currently available, some of which had a large number of patients and follow-up of up to 4 years. These studies indicate that this strategy is safe and efficacious, thus allowing its clinical use when indicated. This strategy may be especially useful in reducing the costs of treatment in countries with scarce economic resources. The role of LPV/r monotherapy in the prevention and management of lipodystrophy and in improving the selection of patients with an optimal risk-benefit ratio remains to be defined.
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Osler M, Stead D, Rebe K, Meintjes G, Boulle A. Risk factors for and clinical characteristics of severe hyperlactataemia in patients receiving antiretroviral therapy: a case-control study. HIV Med 2009; 11:121-9. [PMID: 19702629 DOI: 10.1111/j.1468-1293.2009.00754.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Symptomatic hyperlactataemia and lactic acidosis (SHLA) are potentially life-threatening complications associated with stavudine (d4T), an antiretroviral therapy (ART) drug widely used in developing countries. METHODS Cases comprised all symptomatic patients with measured lactates >or= 5 mmol/L referred to a South African hospital between August 2003 and November 2005. Matched controls were selected according to facility and duration on ART. RESULTS Seventy-one cases and 142 controls were included in the study. The majority of cases presented between 6 and 18 months on ART. Female sex [adjusted odds ratio (AOR) 23.4; 95% confidence interval (CI) 4.0-136.6], a baseline weight between 60 and 75 kg (AOR 4.5; 95% CI 1.4-14.1) or, in particular, >or= 75 kg (AOR 19.4; 95% CI 4.1-82.5) at ART initiation and gaining >or= 6 kg in the first 3 months on therapy (AOR 3.5; 95% CI 1.3-9.5) were independent risk factors identifying patients who may subsequently develop SHLA. Weight loss of >or= 2 kg (AOR 6.1; 95% CI 2.0-18.3), a rise in alanine aminotransferase (ALT) >or= 10 U/L (AOR 3.1; 95% CI 1.1-8.9), the presence of at least one of three major symptoms (vomiting, nausea and abdominal pains) of SHLA (AOR 12.6; 95% CI 3.3-47.2) and peripheral neuropathy (AOR 3.4; 95% CI 1.1-9.8) were the clinical parameters that were most able to identify patients with early manifestations of SHLA. CONCLUSIONS This is the first case-control study for SHLA in Southern Africa. Given these findings, we advise that stavudine is avoided in overweight women. Weight loss, a rise in ALT, peripheral neuropathy and/or gastrointestinal symptoms should prompt healthcare workers to assess for SHLA, especially at between 6 and 18 months on ART.
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Affiliation(s)
- Meg Osler
- Infectious Disease Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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Pérez Valero I. [Prognostic factors of virological response in patients treated with lopinavir/ritonavir monotherapy]. Enferm Infecc Microbiol Clin 2009; 26 Suppl 16:27-33. [PMID: 19572442 DOI: 10.1016/s0213-005x(08)76608-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nine clinical trials have analyzed whether the use of lopinavir-ritonavir (LPV/r) monotherapy could be a valid alternative to triple antiretroviral therapy. Four of these clinical trials included an analysis of risk factors for virological failure. The MONARK study evaluated monotherapy in treatment-naïve patients. The M03-613 trial evaluated monotherapy after a period of induction therapy with triple combination antiretroviral therapy. The study by Sprinz et al and the OK studies evaluated monotherapy as maintenance of virological suppression. The efficacy of monotherapy varied according to the scenario. In the scenario of induction-maintenance, the factors related to virological failure were suboptimal adherence and low baseline CD4 counts. In the scenario of maintenance, the factors related to virological failure were suboptimal adherence, nadir CD4 count and low hemoglobin. In treatment-naive patients, the risk of virological failure increased in patients who did not achieve a viral load of less than 400 copies/ml 4 weeks after initiating treatment and in those infected with non-B subtypes (a factor that was probably also related to suboptimal adherence).
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Westreich DJ, Sanne I, Maskew M, Malope-Kgokong B, Conradie F, Majuba P, Funk MJ, Kaufman JS, Van Rie A, Macphail P. Tuberculosis treatment and risk of stavudine substitution in first-line antiretroviral therapy. Clin Infect Dis 2009; 48:1617-23. [PMID: 19385733 DOI: 10.1086/598977] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Treatment for tuberculosis (TB) is common among individuals receiving stavudine-containing highly active antiretroviral therapy (HAART), but the effect of TB treatment on stavudine toxicity has received little attention. We estimated the effect of TB treatment on risk of stavudine substitution among individuals receiving first-line HAART. METHODS We evaluated a cohort of 7066 patients who initiated HAART from April 2004 through March 2007 in Johannesburg, South Africa. Three exposure categories were considered: ongoing TB treatment at HAART initiation, concurrent initiation of TB treatment and HAART, and incident TB treatment after HAART initiation. The outcome was single-drug stavudine substitution. Adjusted hazard ratios (aHRs) were estimated using marginal structural models to control for confounding, loss to follow-up, and competing risks. RESULTS Individuals with ongoing and concurrent TB treatment were at increased risk of stavudine substitution, irrespective of stavudine dosage. For ongoing TB treatment, aHR was 3.18 (95% confidence interval [CI], 1.82-5.56) in the first 2 months of HAART, 2.51 (95% CI, 1.77-3.54) in months 3-6, and 1.19 (95% CI, 0.94-1.52) thereafter. For concurrent TB treatment, aHR was 6.60 (95% CI, 3.03-14.37) in the first 2 months, 1.88 (95% CI, 0.87-4.09) in months 3-6, and 1.07 (95% CI, 0.65-1.76) thereafter. There was no effect of incident TB on stavudine substitution risk. CONCLUSIONS Risk of stavudine substitution was increased among patients who received TB treatment and was especially elevated during the period soon after HAART initiation. In settings in which alternative antiretroviral drugs are available, initiation of stavudine therapy in patients receiving TB treatment may need to be reconsidered.
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Affiliation(s)
- Daniel J Westreich
- Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC 27599-7435, USA.
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Daher EF, Cezar LC, Silva GB, Lima RS, Damasceno LS, Lopes EB, Nunes FR, Mota RS, Libório AB. Metabolic acidosis in AIDS patients. Arch Med Res 2009; 40:109-13. [PMID: 19237020 DOI: 10.1016/j.arcmed.2008.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Accepted: 11/14/2008] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND AIMS Metabolic acidosis (MA) is a frequent and serious complication in HIV-infected patients. The aim of the study is to compare patients with and without MA associated with HIV. METHODS Patients were retrospectively studied involving all HIV-infected patients with blood gas analysis performed during hospital stay admitted to a single hospital between April 2004 and July 2006. Statistical analysis was performed using SPSS 10.0 for Windows. RESULTS Included in the study were 159 HIV patients, 72 cases (45.3%) with MA and 87 cases (54.7%) without. The comparison of both groups showed a mean arterial pH of 7.24 +/- 0.08 vs. 7.44 +/- 0.05, HCO(3) 12 +/- 5.7 vs. 21 +/- 5.1 mEq/L, serum urea 81 +/- 68 mg/dL vs. 39 +/- 46 mg/dL and serum creatinine 2.7 +/- 2.6 mg/dL vs. 1.2 +/- 1.9 mg/dL in MA-HIV and non-MA-HIV, respectively (p <0.05). Antiretroviral therapy (ART) was being administered to 38 subjects (52.8%) in MA-HIV group and 45 (51.7%) in non-MA-HIV group (p = 0.57). There was no association between the use of ART and MA. Mortality was higher in patients with acidosis (52.7 vs. 17.2%, p <0.0001). CONCLUSIONS In the present study, MA was associated with acute kidney injury and increased mortality. There was no association between the use of ART and MA.
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Affiliation(s)
- Elizabeth F Daher
- Department of Internal Medicine, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará, Fortaleza, Brazil.
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Trindade AJ, Huysman A, Huprikar SS, Kim MK. A case study and review of pancreatitis in the AIDS population. Dig Dis Sci 2008; 53:2616-20. [PMID: 18288615 DOI: 10.1007/s10620-008-0200-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 01/01/2008] [Indexed: 12/09/2022]
Abstract
This case study considers a 55-year-old African American woman with the acquired immunodeficiency syndrome (AIDS) who presented with epigastric abdominal pain for 1 week. She was found to have pancreatitis on computed tomography scanning. Unique to this case are the numerous possible etiologies of her pancreatitis. Thus, this case study systematically reviews the different etiologies of pancreatitis in the AIDS population compared to the general population. Furthermore it discusses the management and treatment of pancreatitis in AIDS.
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Affiliation(s)
- Arvind J Trindade
- Department of Medicine, Mount Sinai Medical Center, Mount Sinai School of Medicine, 1470 Madison Ave, One Gustave L. Levy Place, New York, NY 10029, USA.
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Stead D, Osler M, Boulle A, Rebe K, Meintjes G. Severe Hyperlactataemia Complicating Stavudine First-Line Antiretroviral Therapy in South Africa. Antivir Ther 2008. [DOI: 10.1177/135965350801300712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background In the public sector antiretroviral therapy (ART) programme in South Africa the standardized first-line regimen includes stavudine (d4T). Severe symptomatic hyperlactataemia (SHL) is a potentially life- threatening complication of d4T. Methods GF Jooste Hospital is a referral centre for six ART clinics. We retrospectively reviewed cases referred with lactate levels ≥5 mmol/l that were attributed to nucleoside reverse transcriptase inhibitors from August 2003 to November 2005. We calculated cumulative ART exposure in patients attending these clinics to derive a referral rate. Results In total, 75 patients were referred with severe SHL (71 female). All had been on d4T and on ART for a median of 10 months. The referral rate for severe SHL was 17.5 cases per 1,000 patient-years. In 53 patients (71%), lactic acidosis (standard bicarbonate [SHCO3]<20 mmol/l) was confirmed, resulting in a referral rate of 12.3 cases per 1,000 patient-years. Twelve patients (16%) died during acute admission (≤30 days). SHCO3<15 mmol/l and pH<7.2 were the only factors associated with acute mortality (odds ratio [OR] 22.5, 95% confidence interval [CI] 2.8–1,045.7 and OR 13.9, 95% CI 2.7–86.9, respectively). A total of 30 less severe cases were rechallenged with zidovudine without recurrence of SHL. Conclusions This study confirms a high incidence of severe SHL in Africa, which has been shown in previous studies. Rechallenge with zidovudine in less severe cases was found to be safe.
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Affiliation(s)
- David Stead
- GF Jooste Hospital, Cape Town, South Africa
- Médicins Sans Frontières, Cape Town, South Africa
| | - Meg Osler
- Infectious Disease Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
| | - Andrew Boulle
- Infectious Disease Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kevin Rebe
- GF Jooste Hospital, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- GF Jooste Hospital, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Venkat A, Piontkowsky DM, Cooney RR, Srivastava AK, Suares GA, Heidelberger CP. Care of the HIV-Positive Patient in the Emergency Department in the Era of Highly Active Antiretroviral Therapy. Ann Emerg Med 2008; 52:274-85. [DOI: 10.1016/j.annemergmed.2008.01.324] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 01/08/2008] [Accepted: 01/16/2008] [Indexed: 01/16/2023]
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In vivo assessment of mitochondrial toxicity. Drug Discov Today 2008; 13:785-90. [DOI: 10.1016/j.drudis.2008.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 05/15/2008] [Accepted: 05/16/2008] [Indexed: 11/22/2022]
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Nelson M, Azwa A, Sokwala A, Harania RS, Stebbing J. Fanconi syndrome and lactic acidosis associated with stavudine and lamivudine therapy. AIDS 2008; 22:1374-6. [PMID: 18580619 DOI: 10.1097/qad.0b013e328303be50] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We report a case of the nucleoside reverse transcriptase inhibitors, stavudine and lamivudine inducing Fanconi syndrome in a patient. The presence of simultaneous lactic acidosis suggests mitochondrial toxicity within the proximal renal tubular cells as the likely pathogenesis. We recommend that both the above nucleosides be added to the list of antiretroviral drugs that can induce Fanconi syndrome and that patients on stavudine and lamivudine be monitored carefully for early signs of Fanconi syndrome.
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Sundaram M, Srinivas CN, Shankar EM, Deepak M, Murugavel KG, Balakrishnan P, Solomon S, Kumarasamy N. Co-factors for abnormal lactate levels among persons with HIV disease at a tertiary HIV care setting in South India. Food Chem Toxicol 2008; 46:2823-5. [PMID: 18586371 DOI: 10.1016/j.fct.2008.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 04/28/2008] [Accepted: 05/16/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND The co-factors underlying abnormal lactate level remains to be determined in resource-limited settings. In a cross-sectional study conducted between January 2004 and July 2006, we determined the proportion of HIV-infected persons with abnormal lactate levels and correlated the association of certain co-factors of abnormal lactate levels at a tertiary HIV care centre in Chennai, Southern India. METHODS Lactate was estimated by the enzymatic method using an Olympus AU 400 autoanalyzer. Absolute CD4+T lymphocyte count was determined by the Guava personal cell analyser (Guava Technologies Inc., Hayward, CA, USA). Subjects were classified to have normal or abnormal values of lactate based on the reference interval (0.3-2.2 mmol/L). A p value 0.05 was considered statistically significant. RESULTS A total of 225 HIV-infected individuals (HAART experienced 213 (95%) and HAART naïve (5%)) were included in the analysis. Mean age was 34+/-8 and 36+/-9 years for the individuals with normal and abnormal lactate levels respectively. Of these 185 (82%) had normal (0.3-2.2 mmol/L) and 40 (18%) had abnormal (>2.2 mmol/L) lactate levels. Significant difference in relation to female gender was observed between the normal and abnormal groups (p=0.03). Among the abnormal group, 39 (97.5%) subjects were HAART experienced compared to 174 (94.1%) normal group. Among the abnormal group, 24 (60%) individuals had a CD4 count of <200 cells/microL as compared to 76 (41.1%) normal subjects. CONCLUSION Female gender should be carefully monitored with respect to their clinical, laboratory and biological data to diminish the occurrence of lactic acidosis.
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Affiliation(s)
- Muthu Sundaram
- YRG Centre for AIDS Research and Education (YRG CARE), Voluntary Health Services, Rajiv Gandhi Salai, Chennai 600 113, India
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