Academy Exchange

Good afternoon,

Hoping to ask assistance changing ART regimen for a 70 y/o male with HIV virally suppressed on abacavir/lamivudine + efavirenz. He has no known resistance. His PMH is significant for osteoporosis, HTN, HLD, CKD3a, and epilepsy well managed on phenytoin BID. He reports chronic fatigue and so I'd like to modify his regimen to eliminate efavirenz (to help with fatigue) and abacavir (to remove added cardiac risk). His previous provider had deferred changing his regimen due to concern that stopping efavirenz may precipitate seizure activity because of the interaction between efavirenz and phenytoin. It looks like there is considerable interaction between ARVs and phenytoin, but that dolutegravir/lamivudine daily with a second dose of dolutegravir 12 hours later may be reasonable. I'd greatly appreciate recommendations about how often to monitor viral suppression and serum phenytoin during the transition, and any other considerations I may have overlooked. 

Thank you,

Emily Delmotte

Good afternoon,

Hoping to ask assistance changing ART regimen for a 70 y/o male with HIV virally suppressed on abacavir/lamivudine + efavirenz. He has no known resistance. His PMH is significant for osteoporosis, HTN, HLD, CKD3a, and epilepsy well managed on phenytoin BID. He reports chronic fatigue and so I'd like to modify his regimen to eliminate efavirenz (to help with fatigue) and abacavir (to remove added cardiac risk). His previous provider had deferred changing his regimen due to concern that stopping efavirenz may precipitate seizure activity because of the interaction between efavirenz and phenytoin. It looks like there is considerable interaction between ARVs and phenytoin, but that dolutegravir/lamivudine daily with a second dose of dolutegravir 12 hours later may be reasonable. I'd greatly appreciate recommendations about how often to monitor viral suppression and serum phenytoin during the transition, and any other considerations I may have overlooked. 

Thank you,

Emily Delmotte

Hi Emily,

It sound like your patient has done well until now on his current meds.  But I am worried about using phenytoin with efavirenz.  He could end up with subtherapeutic efavirenz levels and virologic failure.  In addition, efavirenz inhibits metabolism of phenytoin, and toxic levels could be the result.    As this patient ages, these effects may become more pronounced.  How about seeing if you (and his Neurologist) can change his anti convulsant to levetiracetam (keppra), since this med is not metabolized by the cytochrome P450 system.  This would allow you to change his ARVs to a modern regimen with less cardiovascular and neurologic risk.

Good afternoon,

Hoping to ask assistance changing ART regimen for a 70 y/o male with HIV virally suppressed on abacavir/lamivudine + efavirenz. He has no known resistance. His PMH is significant for osteoporosis, HTN, HLD, CKD3a, and epilepsy well managed on phenytoin BID. He reports chronic fatigue and so I'd like to modify his regimen to eliminate efavirenz (to help with fatigue) and abacavir (to remove added cardiac risk). His previous provider had deferred changing his regimen due to concern that stopping efavirenz may precipitate seizure activity because of the interaction between efavirenz and phenytoin. It looks like there is considerable interaction between ARVs and phenytoin, but that dolutegravir/lamivudine daily with a second dose of dolutegravir 12 hours later may be reasonable. I'd greatly appreciate recommendations about how often to monitor viral suppression and serum phenytoin during the transition, and any other considerations I may have overlooked. 

Thank you,

Emily Delmotte

Good afternoon,

Hoping to ask assistance changing ART regimen for a 70 y/o male with HIV virally suppressed on abacavir/lamivudine + efavirenz. He has no known resistance. His PMH is significant for osteoporosis, HTN, HLD, CKD3a, and epilepsy well managed on phenytoin BID. He reports chronic fatigue and so I'd like to modify his regimen to eliminate efavirenz (to help with fatigue) and abacavir (to remove added cardiac risk). His previous provider had deferred changing his regimen due to concern that stopping efavirenz may precipitate seizure activity because of the interaction between efavirenz and phenytoin. It looks like there is considerable interaction between ARVs and phenytoin, but that dolutegravir/lamivudine daily with a second dose of dolutegravir 12 hours later may be reasonable. I'd greatly appreciate recommendations about how often to monitor viral suppression and serum phenytoin during the transition, and any other considerations I may have overlooked. 

Thank you,

Emily Delmotte