Efavirenz challenge in patients with nevirapine induced Stevens-Johnson Syndrome

• Main Authors: Thandekile C. Manzini, Bernadett I. Gosnell, Melanie-Anne A. John, Mahomed Y. S. Moosa
• Format: Article
• Language: English
• Published: AOSIS 2016-12-01
• Series: Southern African Journal of Infectious Diseases
• Subjects: efavirenz; nevirapine; stevens-johnson syndrome
• Online Access: https://sajid.co.za/index.php/sajid/article/view/75
• ISSN: 2312-0053; 2313-1810

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.