(Last updated: February 12, 2014; last reviewed: February 12, 2014)
|Adverse Effects||Associated ARVs||Onset / Clinical Manifestations||Estimated Frequency||Risk Factors||Prevention/ Monitoring||Management|
Elevated AST, ALT, clinical hepatitis
|All ARVs may be associated with hepatitis. NVP and TPV are of particular concern.
NVP, EFV, ABC, RAL, and MVC have been associated with hypersensitivity reactions.
NRTIs (especially ZDV, ddI, and d4T) are associated with lactic acidosis and hepatic steatosis.
||Uncommon in children.
Frequency varies with different agents and drug combinations.
|HBV or HCV coinfection
Elevated baseline ALT and AST
Other hepatotoxic medications (including herbal preparations such as St. John's wort [Hypericum perforatum], Chaparral [Larrea tridentate], Germander [Teudrium chamaedrys])
Underlying liver disease
For NVP-Associated Hepatic Events in Adults:
For ARVs Other than NVP:
|Asymptomatic patients with elevated ALT or AST should be evaluated for other causes and monitored closely. If ALT or AST >5 to 10 times ULN, some would consider discontinuing ARVs.
In symptomatic patients, discontinue all ARVs and other potential hepatotoxic agents and avoid restarting the offending agent.
If a symptomatic hepatic event occurs on NVP, permanently discontinue drug (see also NVP Hypersensitivity).
When clinical hepatitis is associated with lactic acidosis, avoid restarting the most likely agent, and ZDV, d4T, and ddI in particular (see also Lactic Acidosis).
Consider viral causes of hepatitis: HAV, HBV, HCV, EBV, and CMV.
|Indirect Hyperbilirubinemia||IDV, ATV||Onset:
||HIV-Infected Children Receiving ATV:
||Not necessary to discontinue the offending agent except for cosmetic reasons.
After an initial rise over the first few months of therapy, unconjugated bilirubin levels generally stabilize; in some patients, levels improve over time.
|Non-Cirrhotic Portal Hypertension||ARVs, especially ddI, d4T and combination of ddI and d4T||Onset:
||Prolonged exposure to ARV therapy, especially ddI and the combination of ddI and d4T||Monitoring:
||Manage complications of GI bleeding and esophageal varices.
replace d4T or ddI, if patient is receiving either.