Adverse Effects
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NRTIs
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NNRTIs
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PIs
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INSTI
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EI
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Bleeding events |
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All PIs: Increased spontaneous bleeding, hematuria in patients with hemophilia
TPV: Reports of intracranial hemorrhage. Risks include CNS lesions, trauma, surgery, hypertension, alcohol abuse, coagulopathy, and concomitant use of anti-coagulant or anti-platelet agents, including vitamin E |
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Bone marrow suppression |
ZDV: Anemia, neutropenia |
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Cardiovascular disease (CVD) |
ABC and ddI: Associated with an increased risk of MI in some, but not all, cohort studies. Absolute risk greatest in patients with traditional CVD risk factors. |
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PIs: Associated with MI and stroke in some cohort studies. Data on newer PIs (ATV, DRV, and TPV) are limited.
SQV/r, ATV/r, and LPV/r: PR interval prolongation. Risks include structural heart disease, conduction system abnormalities, cardiomyopathy, ischemic heart disease, and coadministration with drugs that prolong PR interval.
SQV/r: QT interval prolongation in patients in a healthy volunteer study. Risks include underlying heart conditions, pre-existing prolonged QT or arrhythmia, or use with other QT-prolonging drugs. ECG is recommended before SQV initiation and should be considered during therapy.
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Central nervous system (CNS) effects |
d4T: Associated with rapidly progressive, ascending neuromuscular weakness resembling Guillain-Barré syndrome (rare) |
EFV: Somnolence, insomnia, abnormal dreams, dizziness, impaired concentration, depression, psychosis, and suicidal ideation. Symptoms usually subside or diminish after 2–4 weeks. Bedtime dosing may reduce symptoms. Risks include history of psychiatric illness, concomitant use of agents with neuropsychiatric effects, and increased plasma EFV concentrations due to genetic factors or increased absorption with food. |
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RAL: Depression (uncommon) |
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Cholelithiasis |
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ATV:
- History of kidney stones increases risk and patients may present with cholelithiasis and kidney stones concurrently
- Typically presents as abdominal pain
- Reported complications include cholecystitis, pancreatitis, choledocholithiasis, and cholangitis
- Median time to onset is 42 months (range 1–90 months)
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Diabetes mellitus (DM)/insulin resistance |
ZDV, d4T, and ddI |
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- Reported for some PIs (IDV, LPV/r), but not all PIs
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Dyslipidemia |
d4T > ZDV > ABC:
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EFV
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↑ LDL, ↑ TG, ↑ HDL: All RTV-boosted PIs
↑ TG:
LPV/r = FPV/r and LPV/r > DRV/r and ATV/r
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Gastrointestinal (GI) effects |
Nausea and vomiting:
ddI and ZDV > other NRTIs
Pancreatitis: ddI
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GI intolerance (e.g., diarrhea, nausea, vomiting)
Diarrhea:
Common with NFV;
LPV/r > DRV/r and ATV/r
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Nausea and diarrhea:
EVG/COBI/TDF/FTC
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Hepatic effects |
Reported for most NRTIs
ddI: Prolonged exposure linked to non-cirrhotic portal hypertension, some cases with esophageal varicees
Steatosis: Most commonly seen with ZDV, d4T, or ddI
Flares: HIV/HBV-co-infected patients may develop severe hepatic flares when TDF, 3TC, and FTC are withdrawn or when HBV resistance develops.
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NVP > other NNRTIs
NVP:
- Severe hepatic toxicity with NVP is often associated with skin rash or symptoms of hypersensitivity.
- In ARV-naive patients, risk is greater for women with pre-NVP CD4 count >250 cells/mm3 and men with pre-NVP CD4 count >400 cells/mm3. Overall risk is higher for women than men.
- Risk is greatest in the first few months of treatment.
- 2-week dose escalation of NVP reduces risk of rash and possibly hepatotoxicity if related to hypersensitivity.
- NVP is contraindicated in patients with moderate to severe hepatic insufficiency (Child-Pugh classification B or C).
- Liver failure observed in HIV-uninfected individuals receiving NVP for post-exposure prophylaxis. NVP should never be used for this indication.
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All PIs: Drug-induced hepatitis and hepatic decompensation (and rare cases of fatalities) have been reported with all PIs to varying degrees. The frequency of hepatic events is higher with TPV/r than with other PIs.
IDV, ATV: Jaundice due to indirect hyperbilirubinemia
TPV/r: Contraindicated in patients with moderate to severe hepatic insufficiency (Child Pugh classification B or C)
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MVC: Hepatotoxicity with or without rash or HSRs reported |
Hypersensitivity reaction (HSR)
(excluding rash alone or Stevens-Johnson syndrome [SJS]) |
ABC:
- HLA-B*5701 screening should be performed before initiation of ABC. ABC should not be started if the HLA-B*5701 test result is positive.
- Symptoms of HSR include (in descending frequency): fever, skin rash, malaise, nausea, headache, myalgia, chills, diarrhea, vomiting, abdominal pain, dyspnea, arthralgia, and respiratory symptoms.
- Symptoms worsen with continuation of ABC.
- Median onset of reactions is 9 days; approximately 90% of reactions occur within the first 6 weeks of treatment.
- The onset of re-challenge reactions is within hours of re-challenge dose
- Patients, regardless of HLA-B*5701 status, should not be re-challenged with ABC if HSR is suspected.
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NVP:
- Hypersensitivity syndrome of hepatic toxicity and rash that may be accompanied by fever, general malaise, fatigue, myalgias, arthralgias, blisters, oral lesions, conjunctivitis, facial edema, eosinophilia, granulocytopenia, lymphadenopathy, or renal dysfunction.
- In ARV-naive patients, risk is greater for women with pre-NVP CD4 count >250 cells/mm3 and men with pre-NVP CD4 count >400 cells/mm3. Overall, risk is higher for women than men.
- 2-week dose escalation of NVP reduces risk.
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RAL |
MVC: Reported as part of a syndrome related to hepatotoxicity |
Lactic acidosis |
NRTIs, especially d4T, ZDV, and ddI:
- Insidious onset with GI prodrome, weight loss, and fatigue. May be rapidly progressive with tachycardia, tachypnea, jaundice, muscular weakness, mental status changes, respiratory distress, pancreatitis, and organ failure.
- Mortality up to 50% in some case series, especially in patients with serum lactate >10 mmol/L
- Females and obese patients at increased risk
Laboratory findings:
- ↑ lactate (often >5 mmol/L), anion gap, AST, ALT, PT, bilirubin
- ↑ amylase and lipase in patients with pancreatitis
- ↓ arterial pH, serum bicarbonate, serum albumin
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Lipodystrophy |
Lipoatrophy: Thymidine analogs (d4T > ZDV). May be more likely when NRTIs combined with EFV than with a RTV-boosted PI. |
Lipohypertophy: Trunk fat increase observed with EFV-, PI-, and RAL-containing regimens; however, causal relationship has not been established. |
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Myopathy/elevated creatine phosphokinase (CPK) |
ZDV: Myopathy |
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RAL: ↑ CPK
Muscle weakness and rhabdomyolysis
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Nephrotoxicity/
urolithiasis
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TDF: ↑ serum creatinine, proteinuria, hypophosphatemia, urinary phosphate wasting, glycosuria, hypokalemia, non-anion gap metabolic acidosis
Concurrent use with PI appears to increase risk.
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IDV: ↑ serum creatinine, pyuria; hydronephrosis or renal atrophy
IDV, ATV: Stone, crystal formation; adequate hydration may reduce risk.
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EVG/COBI/TDF/FTC:
- COBI can cause non-pathologic decrease in CrCl.
- May increase risk of TDF-related nephrotoxicity
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Osteopenia/
osteoporosis
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TDF: Associated with greater loss of BMD than with ZDV, d4T, and ABC. |
Decreases in BMD observed in studies of regimens containing different NRTIs combined with either NNRTIs or PIs. |
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Peripheral neuropathy |
Peripheral neuropathy (pain and/or paresthesias, lower extremities > upper extremities): d4T > ddI and ddC (can be irreversible) |
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Rash |
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All NNRTIs |
ATV, DRV, FPV |
RAL, EVG/COBI/TDF/FTC: Uncommon |
MVC |
Stevens-Johnson syndrome (SJS)/ toxic epidermal necrosis (TEN) |
ddI, ZDV: Reported cases |
NVP > DLV, EFV, ETR, RPV |
FPV, DRV, IDV, LPV/r, ATV: Reported cases |
RAL |
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