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Symptomatic hyperbilirubinemia with indinavir/ritonavir-containing regimen
C R Rayner1, L D Esch, H E Wynn
1Department of Pharmacy Practice, Monash University, Parkville, Victoria, Australia. craig.rayner@vcp.monash.edu.au
The Annals of Pharmacotherapy
|November 29, 2001
Summary
Ritonavir added to indinavir antiretroviral therapy caused severe hyperbilirubinemia and anemia. This case highlights potential adverse effects of drug interactions in HIV treatment.
Area of Science:
- Pharmacology
- Hepatology
- Infectious Diseases
Background:
- Combination antiretroviral therapy (ART) is standard for HIV treatment.
- Protease inhibitor regimens have improved pharmacokinetic profiles.
- Drug interactions can lead to unexpected adverse effects.
Observation:
- A 27-year-old woman developed symptomatic hyperbilirubinemia and anemia on an indinavir/ritonavir ART regimen.
- Laboratory tests revealed unconjugated hyperbilirubinemia due to indinavir and anemia due to zidovudine.
- Therapy disruption was necessary due to the adverse events.
Findings:
- Severe hyperbilirubinemia was attributed to high indinavir concentrations, caused by ritonavir's metabolic inhibition.
- Anemia was consistent with zidovudine-induced erythrocyte maturation arrest, not hemolysis.
- Indinavir-induced hyperbilirubinemia is typically mild and dose-related, but ritonavir co-administration exacerbated it.
Implications:
- Clinicians must consider potential severe adverse effects from drug interactions in ART, even with pharmacokinetic enhancements.
- This case underscores the importance of monitoring for unexpected toxicities in complex HIV treatment regimens.
- Understanding drug metabolism and interactions is crucial for managing HIV patients safely and effectively.