A 60-year-old man was on antiretroviral therapy (ART) with Dolutegravir plus rilpivirine. He was either on chronic therapy with furosemide, aldactone, bisoprolole, enalapril, metphormine for co-morbidity (diabetes, hypertension, ischemic cardiopathy).
His creatinine level increased from 1.5 mg/dl (eGFR=48) to 4.2 mg/dl (eGFR=15).
Is necessary to change ART? Do you stop DLT?
Dear Dr. De Socio
let me suggest an answer citing Maggi P. et al In "Novel antiretroviral drugs and renal function monitoring of HIV patients" (PMID: 25102336):
Rilpivirine, cobicistat, and dolutegravir reduce the tubular secretion of creatinine, inducing a decrease of estimated glomerular filtration rate according to creatinine. Rilpivirine and dolutegravir block the uptake of creatinine from the blood, inhibiting organic cation transporter 2, and cobicistat interacts with the efflux inhibiting multidrug and toxin extrusion protein 1. This effect can then be considered a "reset" of the estimated glomerular filtration rate according to creatinine. However, clinicians should carefully monitor renal function in order to identify possible alterations suggestive of a true renal functional impairment".
Moreover there are some evidences of interactions between DLT and metformin (plasma levels of metformin could be significantly increased) so they should not be co-administrated.
Thus in my opinion ART should be modified according to previous pharmacoresistance tests (e.g. PI/r + NRTI such as ABC alone?).
Best wishes,
Cinzia Puzzolante
Dear collegues, the case is complex. This patient is suffering from diabetes, hypertension and ischemic cardiopathy for previous acute myocardial infarction. His renal function is severely impaired (eGFR=15 ml/min). We have relevant renal and cardiovascular concern. In this context Abacavir and booster PI are not the best options. HIV genotype showed no drug resistances. Do you stop DLT?
No dosage adjustment
https://aidsinfo.nih.gov/guidelines/.../arv-dosing-for-renal-or-hepatic-insufficiency
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