October 27, 2001
The subject of nevirapine (NVP, Viramune) liver toxicity is controversial. Clearly there is a hypersensitivity reaction (allegoric reaction) in some patients who start nevirapine. This is more likely to happen in people with >350 CD4 cells, women and people with African heritage. However, whether there is long-term toxicity after the first four weeks due more to nevirapine than to other NNRTIs is still up in the air.
There was an intriguing poster in Buenos Aires that indicated that higher nevirapine levels in hepatitis C-infected persons lead to more liver toxicity, which makes sense. This was confirmed at the Athens 3rd Workshop on Adverse Events and Lipodystrophy by a small series of patients from California who had HCV and were taking nevirapine. Some were treated for their HCV with interferon and ribavirin. The basic concept here is that there were some elevations of liver enzymes in the group, none severe, which they resolved on their own without the patients having to stop the nevirapine. It is a well-known phenomenon in patients with HCV that liver tests wax and wane and it is important not to blame the nevirapine for the rising levels.
This group of patients had been taking nevirapine for a while before this study and showed that they were not going to be allergic to nevirapine. The take-home point is that while nevirapine has had some bad press in recent years, it is not particularly liver-toxic even in HCV patients and that it certainly can be used with success. All drugs have some toxicities and it is only one of the criteria physicians and patients should use in picking an HIV drug.
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