Academy Exchange

Hoping to receive guidance on whether ART modification is warranted in a patient with elevated liver enzymes on rilpivirine/emtricitabine/TAF. Patient is a 58 y/o M diagnosed with HIV in 1998 and started ART shortly after with lamivudine/zidovudine + nevirapine. Records from an outside health system note that he was on a Truvada-based regimen which was discontinued due to recurrent fracture and injuries, and was on Triumeq which was discontinued due to diaphoresis. Cabenuva was considered but decided against due to INSTI mutation G140A on proviral genotype. When I first saw him he had returned to lamivudine/zidovudine + nevirapine and had ALT/AST/Alk phos elevated at <2x ULN. Bilirubin WNL. Liver u/s suggestive of MASLD. I switched him to rilpivirine/emtricitabine/TAF 10/2024 for improved side effect profile. Following the switch his liver enzymes remained elevated at <2x ULN, and bilirubin has slowly increased to 2.3. His PCP is concerned that ART is the cause for elevated liver enzymes, and I'm wondering whether a change is necessitated? PMH also includes T2DM, currently well controlled, chronic pain, and anxiety and depression. 

Hoping to receive guidance on whether ART modification is warranted in a patient with elevated liver enzymes on rilpivirine/emtricitabine/TAF. Patient is a 58 y/o M diagnosed with HIV in 1998 and started ART shortly after with lamivudine/zidovudine + nevirapine. Records from an outside health system note that he was on a Truvada-based regimen which was discontinued due to recurrent fracture and injuries, and was on Triumeq which was discontinued due to diaphoresis. Cabenuva was considered but decided against due to INSTI mutation G140A on proviral genotype. When I first saw him he had returned to lamivudine/zidovudine + nevirapine and had ALT/AST/Alk phos elevated at <2x ULN. Bilirubin WNL. Liver u/s suggestive of MASLD. I switched him to rilpivirine/emtricitabine/TAF 10/2024 for improved side effect profile. Following the switch his liver enzymes remained elevated at <2x ULN, and bilirubin has slowly increased to 2.3. His PCP is concerned that ART is the cause for elevated liver enzymes, and I'm wondering whether a change is necessitated? PMH also includes T2DM, currently well controlled, chronic pain, and anxiety and depression. 

Hoping to receive guidance on whether ART modification is warranted in a patient with elevated liver enzymes on rilpivirine/emtricitabine/TAF. Patient is a 58 y/o M diagnosed with HIV in 1998 and started ART shortly after with lamivudine/zidovudine + nevirapine. Records from an outside health system note that he was on a Truvada-based regimen which was discontinued due to recurrent fracture and injuries, and was on Triumeq which was discontinued due to diaphoresis. Cabenuva was considered but decided against due to INSTI mutation G140A on proviral genotype. When I first saw him he had returned to lamivudine/zidovudine + nevirapine and had ALT/AST/Alk phos elevated at <2x ULN. Bilirubin WNL. Liver u/s suggestive of MASLD. I switched him to rilpivirine/emtricitabine/TAF 10/2024 for improved side effect profile. Following the switch his liver enzymes remained elevated at <2x ULN, and bilirubin has slowly increased to 2.3. His PCP is concerned that ART is the cause for elevated liver enzymes, and I'm wondering whether a change is necessitated? PMH also includes T2DM, currently well controlled, chronic pain, and anxiety and depression.