Efavirenz challenge in patients with nevirapine induced Stevens-Johnson Syndrome

Background: Non-nucleoside reverse transcriptase inhibitors (NNRTI) are recommended as part of first-line treatment by the World Health Organisation (WHO) for antiretroviral treatment (ART) naïve subjects. Due to reports of cross-toxicity between nevirapine (NVP) and efavirenz (EFV), there is reluct...

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Published inSouthern African journal of infectious diseases Vol. 31; no. 4; pp. 119 - 121
Main Authors Manzini, Thandekile C., Gosnell, Bernadett I., John, Melanie-Anne A., Moosa, Mahomed Y. S.
Format Journal Article
LanguageEnglish
Published AOSIS 31.12.2016
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Abstract Background: Non-nucleoside reverse transcriptase inhibitors (NNRTI) are recommended as part of first-line treatment by the World Health Organisation (WHO) for antiretroviral treatment (ART) naïve subjects. Due to reports of cross-toxicity between nevirapine (NVP) and efavirenz (EFV), there is reluctance to substitute EFV for NVP when serious toxicity occurs. In such cases lopinavir/ritonavir (LPV/r) remains the only alternative. We report on our experience of patients with Stevens-Johnson Syndrome (SJS) secondary to NVP who were challenged with EFV under careful supervision.Methods: A retrospective chart review of patients who presented with SJS presumed to be secondary to NVP who were challenged with EFV and were followed up for at least 2 months.Results: The study included 13 patients. All were female, median age 28 years and median weight 66.5 kg. The median CD4 cell count at ART initiation was 160 cells/μl. Twelve patients (92%) developed a rash within 4 weeks of NVP. The median alanine transaminase at SJS presentation was 30 U/l. The median time to EFV challenge was 30 days. The median hospital stay for SJS was 30 days and median follow up was 19 months. Eleven (85%) patients tolerated co-trimoxazole rechallenge, two had no prior exposure. Median hospital stay for EFV challenge was additional 10 days. Twelve patients (92%) tolerated the EFV challenge. One patient developed a pruritic maculo-papular eruption within 3 days of challenge which led to discontinuation of EFV.Conclusion: The risk of recurrence of SJS with EFV challenge in patients with NVP induced SJS is low. It is safe to challenge patients with EFV with careful observation.
AbstractList Background: Non-nucleoside reverse transcriptase inhibitors (NNRTI) are recommended as part of first-line treatment by the World Health Organisation (WHO) for antiretroviral treatment (ART) naïve subjects. Due to reports of cross-toxicity between nevirapine (NVP) and efavirenz (EFV), there is reluctance to substitute EFV for NVP when serious toxicity occurs. In such cases lopinavir/ritonavir (LPV/r) remains the only alternative. We report on our experience of patients with Stevens-Johnson Syndrome (SJS) secondary to NVP who were challenged with EFV under careful supervision. Methods: A retrospective chart review of patients who presented with SJS presumed to be secondary to NVP who were challenged with EFV and were followed up for at least 2 months. Results: The study included 13 patients. All were female, median age 28 years and median weight 66.5 kg. The median CD4 cell count at ART initiation was 160 cells/μl. Twelve patients (92%) developed a rash within 4 weeks of NVP. The median alanine transaminase at SJS presentation was 30 U/l. The median time to EFV challenge was 30 days. The median hospital stay for SJS was 30 days and median follow up was 19 months. Eleven (85%) patients tolerated co-trimoxazole rechallenge, two had no prior exposure. Median hospital stay for EFV challenge was additional 10 days. Twelve patients (92%) tolerated the EFV challenge. One patient developed a pruritic maculo-papular eruption within 3 days of challenge which led to discontinuation of EFV. Conclusion: The risk of recurrence of SJS with EFV challenge in patients with NVP induced SJS is low. It is safe to challenge patients with EFV with careful observation.
Author Manzini, Thandekile C.
Moosa, Mahomed Y. S.
Gosnell, Bernadett I.
John, Melanie-Anne A.
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SubjectTerms efavirenz
nevirapine
stevens-johnson syndrome
Title Efavirenz challenge in patients with nevirapine induced Stevens-Johnson Syndrome
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