Mechanisms include hypersensitivity (e.g., with nevirapine, other NNRTIs, darunavir and fosamprenavir) where concomitant rash may occur, mitochondrial toxicity and steatosis (e.g., with d4T, ddI and ZDV), and direct hepatic toxicity (e.g., with ddI and tipranavir) [2,4]. The greatest risk of ARV-induced hepatotoxicity
is observed in those with advanced liver disease. Didanosine (ddI), stavudine (d4T) and ritonavir-boosted tipranavir should be avoided and zidovudine (ZDV) only used in the absence of an alternative option [8–11]; nevirapine should be used with caution. In addition, didanosine is associated with non-cirrhotic portal hypertension . Some retrospective studies Epigenetic inhibitor have shown abacavir to be associated with a decreased response to PEG-IFN/RBV therapy in patients treated for HCV genotype 1 infection, possibly due to intracellular reductions in ribavirin level (see Section 8). Several factors (use of non-weight-based RBV dosing and differential baseline HCV viral loads) have made these data difficult to interpret and the findings have recently been disputed . Nevertheless, we advise when abacavir is to be used, ribavirin should be dosed ≥1000 mg or ≥13.2 mg/kg [14–16]. Individuals may develop immune restoration on initiation of ART and need to be carefully monitored for hepatotoxicity Selleckchem Afatinib when ART is commenced or changed
[17–18]. See Sections 6 and 8 for recommendations on ARV use when treating HBV and HCV coinfection. In addition, when DAAs are chosen, there are restrictions on choice of first-line ARV due to drug-drug interactions [19–23]. 1 Sulkowski MS, Thomas DL, Chaisson RE et al. Hepatotoxicity associated with antiretroviral therapy in adults infected with human immunodeficiency virus and the role of hepatitis C or B virus infection. JAMA 2000; 283: 74–80. 2 Puoti M, Nasta P, Gatti F et al. HIV-related liver disease: ARV drugs, coinfection, and other risk factors. J Int Assoc Physicians AIDS Care (Chic Ill) 2009; 8: 30–42. 3 Aranzabal L, Casado JL, Moya J et al. Influence of
liver fibrosis on highly active antiretroviral therapy-associated hepatotoxicity in patients with HIV and hepatitis C virus coinfection. Clin Infect Dis 2005; 40: 588–593. 4 Soriano V, Puoti M, Garcia-Gasco P et al. Antiretroviral drugs and liver injury. AIDS 2008; 22: 1–13. 5 Reisler RB, Han C, Burman WJ et al. Selleck Rucaparib Grade 4 events are as important as AIDS events in the era of HAART. J Acquir Immune Defic Syndr 2003; 34: 379–386. 6 Labarga P, Soriano V, Vispo ME et al. Hepatotoxicity of antiretroviral drugs is reduced after successful treatment of chronic hepatitis C in HIV-infected patients. J Infect Dis 2007; 196: 670–676. 7 Price JC, Thio CL. Liver Disease in the HIV-Infected Individual. Clin Gastroenterol Hepatol 2010; 8: 1002–1012. 8 Nunez M. Hepatotoxicity of antiretrovirals: incidence, mechanisms and management. J Hepatol 2006; 44(Suppl 1): S132–S139. 9 McGovern BH, Ditelberg JS, Taylor LE et al.