Persistence of Macrocytosis after Discontinuation of Zidovudine in HIV-Infected Patients

Long-Term Zidovudine Therapy and Whether It is a Trigger of Vitamin B12 Deficiency: A Case Study of Megaloblastic Anemia at the University of Zambia Teaching Hospital

Macrocytic anemia is frequently observed in adult HIV-infected patients treated with nucleoside reverse transcriptase inhibitors and with vitamin B12 and folate deficiency. In this case report, we discuss a 52-year-old nonvegetarian male on long-term antiretroviral therapy for 5 years, presenting with severe macrocytic anemia (hemoglobin, 3.7 g/dL; mean corpuscular volume, 119.6 fL) and leukopenia (2.71∗10⁹/L), who was diagnosed with megaloblastic anemia caused by vitamin B12 deficiency following laboratory investigations. Parenteral vitamin B12 replacement therapy was initiated, with an early response observed. Notwithstanding, the treatment response was not sustained as the patient later presented with refractory anemia and persistence of macrocytosis. Discontinuation of zidovudine with concurrent vitamin B12 administration promptly improved the patient's clinical deficiency symptoms. At the end of 3 months, the patient had a complete hematological recovery. The deficiency of vitamin B12 disrupts DNA synthesis inhibiting effective hematopoiesis in all cell lines, particularly erythroid precursors and further promotes reversible bone marrow failure. Long-term ART therapy with zidovudine causes cytotoxicity in myeloid and erythroid precursors and induces bone marrow suppression. Whether long-term zidovudine consumption induced lower levels of vitamin B12 and subsequent megaloblastic anemia requires in-depth research and exploration.

Is there a need for shifting patients on long term nevirapine based regimens to efavirenz based regimens: a cross-sectional study?

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are the backbone of effective anti-retroviral therapy in the developing world. Efavirenz is the current NNRTI of choice due to reports of higher incidence of serious adverse events with nevirapine. Majority of patients with Human immunodeficiency virus (HIV) infection in India are still on nevirapine based therapy. The aim of the study was to evaluate the need of shifting these patients to efavirenz based therapy. A cross-sectional study was conducted on adult patients, who were on NNRTI based regimen for more than one year with good adherence. The patients were divided into efavirenz or nevirapine groups based on the treatments they were receiving at the time of study. The different arms were compared based on their clinical and laboratory profile, adverse events and immunological response. A total of 244 patients were recruited. A total of 125 patients were receiving nevirapine based regimen while 119 patients were receiving efavirenz based regimen. There was no significant difference in the frequency of hematological and biochemical derangements between the two groups. There was no difference in the median highest CD4 count achieved during therapy between the two groups. Clinically observed side effects were more common in the efavirenz group. These results suggest that there isn't enough evidence to shift patients tolerating long term nevirapine based therapy to efavirenz based therapy.

Evolution of Anemia Types During Antiretroviral Therapy-Implications for Treatment Outcomes and Quality of Life Among HIV-Infected Adults

This study examined whether the type of anemia in persons living with HIV/AIDS (PLWHA) changed from the beginning of highly antiretroviral therapy (HAART) and had implications for treatment outcomes and quality of life (QOL). If present, the anemia-type was defined as microcytic, macrocytic or anemia of chronic disease (ACD) at study months 0, 6, 12, and 18. Multinomial logistic regression quantified sociodemographic and HIV-treatment factors associated with incident microcytic anemia or ACD over 18 months. Repeated measures linear regression models estimated the anemia-type associated change in the CD4 cell-count, QOL, body mass index (BMI) and frailty over 18 months. Cox proportional hazard models estimated associations between anemia-type and time to (a) gain at least 100 CD4 cells/L and (b) hospitalization/death. Analyses were implemented in Statistical Analysis Software (v.9.4) from which odds ratios (ORs) mean differences (β) and corresponding 95% confidence intervals (CI) were estimated. At enrollment, ACD, macrocytic and microcytic anemia was present in 36.8% (n = 147), 11.3% (n = 45) and 9.5% (n = 38), respectively with 42% (n = 170) anemia-free. By the study end, only 23% (n = 115) were without anemia. Among the 251 with anemia at the study end, 53.3% (n = 195) had macrocytic anemia, 12.8% (n = 47) had ACD and 2.5% (n = 9) had microcytic anemia. Incident macrocytic anemia was positively associated with baseline hyperferritinemia (OR = 1.85, 95%CI: 1.03⁻3.32), inversely associated with wealth (OR = 0.87, 95%CI: 0.67⁻1.03) and inversely associated with efavirenz-containing HAART (OR = 0.42, 95%CI: 0.21⁻0.85). ACD incidence decreased by 53% (95%CI: 0.27⁻0.79) per 100 cells/L increase in baseline CD4-cell count and decreased by 90% (95%CI: 0.01,0.87) among adults treated with nevirapine-containing HAART. ACD was associated with a lower BMI at months 6 (β = -0.33, 95% CI: -0.64, -0.01) and 12 (β = -0.41, 95%CI: -0.73, -0.09), with lower QOL (β = -3.2, 95%CI: -5.94, -0.53) at month 12 and with elevated frailty (β = 1.2; 95%CI: 0.46, 1.86) at month 12. Macrocytic anemia did not predict a post-enrollment change in CD4, BMI or QOL during follow-up. However, the time to gain 100 CD4 cells/L was 43% slower (p < 0.05) and the frailty was higher at month 12 for PLWHA with the baseline or sustained macrocytic vs. no anemia. A substantial decline in ACD and microcytic anemia occurred in tandem with large increase in the macrocytic anemia over 18 months on HAART. Interventions to mitigate all anemia-particularly ACD, is expected to improve the immune recovery rate, lower frailty, and enhanced QOL.