Risk for Immune-Mediated Liver Reactions by Nevirapine Revisited

Implementation of combination antiretroviral therapies has transformed the prognosis of HIV infectionduring the past decade. Because of its low-pill burden, convenient administration once or twicedaily without food restrictions and, in the case of nevirapine, favorable metabolic profile and provensafety in pregnant women and newborns, nonnucleoside reverse transcriptase inhibitors have beenshown to be often superior to protease inhibitors as third agents in combination with a backbone oftwo nucleoside reverse transcriptase inhibitors. Therefore, two nucleoside reverse transcriptase inhibitorsplus one nonnucleoside reverse transcriptase inhibitor are currently the most popular usedfirst-line therapies. Hepatotoxicity during the first weeks of therapy with nevirapine, particularly wheninitiated in women with CD4 counts > 250 cells/mm3, has prompted changes in guidelines and led toa modification in the product label. Recent data, however, suggest that virologically suppressedpatients under any other antiretroviral drug combination may safely switch to nevirapine as a part ofa simplification strategy, regardless of their current CD4 count. This subset of patients does not showan increased risk of hepatotoxicity or rash with elevated CD4 counts, as has been reported in drugnaiveHIV persons. This information is important and may expand the number of candidates whocould benefit from nevirapine use, since a substantial proportion of HIV patients show metabolicabnormalities (dyslipidemia, insulin resistance, liver steatosis) and are at increased cardiovascularrisk. Fortunately, many of these conditions may ameliorate or improve using nevirapine.