772 J Acquir Immune Defic Syndr • Volume 36, Number 3, July 1 2004
J Acquir Immune Defic Syndr • Volume 36, Number 3, July 1 2004 Maternal Toxicity With Continuous Nevirapine
copies/mL and the intention to continue antiretroviral therapy consistent with clinical hepatitis at any grade ALT, or rash
after delivery. Prior zidovudine monotherapy, limited to <8 accompanied by urticaria, mucous membrane involvement or
weeks, was allowed. There was no restriction as to CD4 cell constitutional symptoms. Study personnel at each site were
count at study entry. Women with a baseline alanine amino- responsible for deciding whether non-specific symptoms were
transferase (ALT) greater than 2.5 times the upper limit of nor- possibly consistent with clinical hepatitis and merited treat-
mal, active hepatitis B or C or other serious concurrent illness ment discontinuation.
were not eligible to enroll in the trial. Participating centers in- Enrollment was suspended in August 2003 because of
cluded University of Southern California, State University of greater than expected toxicity and changes in nevirapine pre-
New York at Stony Brook, Columbus Regional Healthcare scribing information that recommended caution for women
System, University of Miami, Baylor College of Medicine, with CD4 cell counts greater than 250 cells/µL. These events
Columbia University, City Hospital at San Juan, University of led to a previously unscheduled intent-to-treat interim analysis
Tennessee Health Science Center, University of Washington, comparing the incidence of treatment-limiting toxicity by arm,
University of Cincinnati, University of California Los Ange- for all subjects and also for the subset of women with an entry
les, Mount Sinai Hospital, University of California San Diego, CD4 cell count greater than 250 cells/µL. A 2-tailed Fisher
Yale University, Howard University, and the Bronx-Lebanon exact test was used to determine statistical significance.
Hospital. The Institutional Review Boards of all centers ap-
proved the study protocol, and all subjects provided written RESULTS
informed consent prior to study entry. Twenty-one subjects were randomized to the nelfinavir
The study protocol included stringent toxicity manage- arm and 18 subjects to the nevirapine arm for a total of 39
ment guidelines that were applied uniformly across all centers. subjects. One subject in the nevirapine arm withdrew before
Abnormal ALT and aspartate aminotransferase (AST) values treatment was dispensed. This report includes follow-up data
were graded according to the Division of AIDS toxicity guide- on the remaining 38 subjects through January 1, 2004. Table 1
lines for adults: Grade 0 < = 1.25 times the upper limit of nor- summarizes the baseline demographic and clinical character-
mal; Grade 1 = 1.25–2.5 times the upper limit of normal; Grade istics, which were similar for each treatment group. Of note,
2 = 2.5–5.0 times the upper limit of normal; Grade 3 = 5.0–10.0 74% of subjects had an entry CD4 cell count greater than
times the upper limit of normal; and Grade 4 = >10 times 250 cells/µL, and all subjects were asymptomatic with respect
the upper limit of normal. Study treatment was stopped for a to HIV-1. The median length of follow-up as of January 1,
confirmed Grade 3 or 4 ALT or AST, any symptoms possibly 2004 was 38 weeks and was similar between treatment arms.
Nelfinavir Nevirapine
(n = 21) (n = 17)
n (%) n (%)
Age (median) 25 28
Race/ethnicity
White 0 (0) 1 (6)
African American 8 (38) 9 (53)
Hispanic 12 (57) 7 (41)
Asian/Pacific Islander 1 (5) 0 (0)
Weeks’ gestation at entry (median, range) 22 (15–30) 20 (14–28)
Weeks of follow-up* (median, range) 37 (20–79) 41 (6–72)
Entry viral load (median and range, copies/mL) 7,762 (1,738–85,114) 9,772 (3,388–67,608)
Entry CD4 count (median and range, cells/µL) 324 (30–912) 359 (99–371)
Entry CD4 > 250 cells/µL 14 (67) 14 (82)
Entry CDC** Category A 21 (100) 17 (100)
Entry ALT*** 1.25–2.5 × upper limit of normal 0 (0) 3 (18)
History of Hepatitis B or C 0 (0) 0 (0)
*As of January 1, 2004.
**Centers for Disease Control and Prevention.
***Alanine aminotransferase.
CD4 cell counts greater than 250 cells/µL who receive continu- pregnant women2,3 raise concern about the safety of continu-
ous nevirapine are at increased risk for hepatic toxicity6 in- ous nevirapine in pregnancy in women with CD4 cell counts
cluding fulminant hepatic failure and death. Men with higher greater than 250 cells/µL. Since these observations agree with
CD4 cell counts are also at increased risk for hepatic toxicity, much larger data sets from non-pregnant women, it would
but at a greater CD4 threshold (400 cells/µL) compared with seem prudent to be cautious in the use of continuous nevirapine
women. Thus, there appears to be an interaction between gen- in pregnant women with CD4 greater than 250 cells/µL. The
der and immunologic status as risk factors for rash-associated safety of nevirapine-containing antiretroviral regimens
hepatic toxicity with continuous nevirapine. While the exact for pregnant women with lower CD4 cell counts deserves
mechanism for nevirapine-associated hepatic toxicity is not additional investigation, especially since continuous nevirap-
understood, an immune-mediated hypersensitivity component ine-containing antiretroviral treatment is rapidly becoming a
is postulated. first-line regimen for pregnant women in resource-limited
It is difficult to estimate the true incidences of treatment- countries.
limiting toxicity and fulminant hepatic failure associated with
continuous nevirapine use in pregnancy. At present, there are ACKNOWLEDGMENTS
no reliable mechanisms to consistently identify and tabulate
The following individuals assisted with conducting
severe but non-fatal toxicity associated with antiretroviral
PACTG 1022: Ana Melendrez, RN, Michael Neely, MD and
therapy in pregnancy occurring outside of the context of a
James Homans, MD, University of Southern California,
clinical trial. Thus, it is unknown whether pregnancy poses an
Los Angeles; Jennifer Griffin, RN, Deborah Hattenback, RN
additional risk for nevirapine-associated hepatic toxicity be-
and Sylvia Muniz, State University of New York, Stony
yond the risk associated with female gender. It is also not pos-
Brook; Dawn Barnes, RN and Anita Whitten, RN, Columbus
sible to determine the incidence of fulminant hepatic failure
Regional Healthcare System; Robert Pass, MD and Terry
and death associated with continuous nevirapine use in preg-
Byars, MD, University of Alabama; Chivon D. Jackson, RN,
nancy, because the number of pregnant women who have re-
Christine M. Owen, RN and Valencia Y. Johnson, RN, Baylor
ceived nevirapine-containing antiretroviral therapy is unknown.
College of Medicine; Alice Higgins, RN and Philip LaRussa,
The data from this and other reports2–4,6 should not be
MD, Columbia University; Midnela Acevedo, MD, Elvia Pérez-
extrapolated to the use of single-dose intrapartum nevirapine
Hernández, MPH and Antonio Rodriguez-Mimoso, MD, City
to prevent mother-to-child HIV-1 transmission. In three large
Hospital at San Juan; Nina Sublette, RN, Pat Flynn, MD, Jill
randomized trials, over 1,600 pregnant women received a
Utech, RN and Mary Dillard, RN, University of Tennessee
single intrapartum dose of nevirapine without any increase in
Health Science Center; Deborah Goldman, ARNP, Michele
maternal toxicity.7–9 Similarly, this report does not imply that
Acker, ARNP and Kathey Mohan, ARNP, University of Wash-
women who initiate nevirapine and tolerate it well should then
ington; Joseph Mrus, MD, Patricia Kohler, RN and Michelle
discontinue nevirapine if they experience immune reconstitu-
Saemann, RN, University of Cincinnati; Margaret A. Keller,
tion. There is no evidence to suggest that immune reconstitu-
MD, Marie Beall, MD and Judy Hayes, RN, University of
tion increases the risk of nevirapine-associated toxicity, re-
California, Los Angeles; Kathy Kabot, Paula Karnick, Gloria
gardless of pregnancy status. It is also not known whether
Seals and Charles Lampley, Mount Sinai Hospital; Andrew D.
antiretroviral-experienced women with immune reconstitution
Hull, MD, Patricia Franklin, FNP, Mary Caffery, RN and Ste-
who switch to a nevirapine-containing regimen would have an
phen A. Spector, MD, University of California, San Diego;
increased risk of hepatic toxicity.
Patricia Strock, PA, Jhoanna Roa, MD, Patricia Houston-Yu,
The major limitation of this study is its small sample
MS and Sohail Rana, MD, Howard University; Saroj Bakshi,
size, which could lead to an overestimate of the incidence of
MD, Murli Purswani, MD, Marilyn Crane, CNM and Mavis
hepatic toxicity associated with nevirapine during pregnancy.
Dummitt, RN, Bronx-Lebanon Hospital.
It is possible that the increased incidence of nevirapine-
associated hepatic adverse events observed in this trial will not
be confirmed in larger data sets. In addition, since the majority REFERENCES
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