Original Research

Efavirenz challenge in patients with nevirapine induced Stevens-Johnson Syndrome

Thandekile C. Manzini, Bernadett I. Gosnell, Melanie-Anne A. John, Mahomed Y. S. Moosa
Southern African Journal of Infectious Diseases | Vol 31, No 4 | a75 | DOI: https://doi.org/10.4102/sajid.v31i4.75 | © 2019 Thandekile C. Manzini, Bernadett I. Gosnell, Melanie-Anne A. John, Mahomed Y. S. Moosa | This work is licensed under CC Attribution 4.0
Submitted: 15 May 2019 | Published: 31 December 2016

About the author(s)

Thandekile C. Manzini, Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
Bernadett I. Gosnell, Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
Melanie-Anne A. John, Enhancing Care Foundation, South Africa, Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa
Mahomed Y. S. Moosa, Department of Infectious Diseases, University of KwaZulu-Natal, Durban, South Africa

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Abstract

Background: Non-nucleoside reverse transcriptase inhibitors (NNRTI) are recommended as part of first-line treatment by the World Health Organisation (WHO) for antiretroviral treatment (ART) naïve subjects. Due to reports of cross-toxicity between nevirapine (NVP) and efavirenz (EFV), there is reluctance to substitute EFV for NVP when serious toxicity occurs. In such cases lopinavir/ritonavir (LPV/r) remains the only alternative. We report on our experience of patients with Stevens-Johnson Syndrome (SJS) secondary to NVP who were challenged with EFV under careful supervision.

Methods: A retrospective chart review of patients who presented with SJS presumed to be secondary to NVP who were challenged with EFV and were followed up for at least 2 months.

Results: The study included 13 patients. All were female, median age 28 years and median weight 66.5 kg. The median CD4 cell count at ART initiation was 160 cells/μl. Twelve patients (92%) developed a rash within 4 weeks of NVP. The median alanine transaminase at SJS presentation was 30 U/l. The median time to EFV challenge was 30 days. The median hospital stay for SJS was 30 days and median follow up was 19 months. Eleven (85%) patients tolerated co-trimoxazole rechallenge, two had no prior exposure. Median hospital stay for EFV challenge was additional 10 days. Twelve patients (92%) tolerated the EFV challenge. One patient developed a pruritic maculo-papular eruption within 3 days of challenge which led to discontinuation of EFV.

Conclusion: The risk of recurrence of SJS with EFV challenge in patients with NVP induced SJS is low. It is safe to challenge patients with EFV with careful observation.


Keywords

efavirenz; nevirapine; Stevens-Johnson Syndrome

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