Decreased plasma efavirenz concentrations in a patient receiving rifabutin

Hsu, Oliver; Hill, Catherine J.; Kim, Mina; Tan, Benny; O'Brien, John G.
October 2010
American Journal of Health-System Pharmacy;10/1/2010, Vol. 67 Issue 19/20, p1611
Academic Journal
Case Study
Purpose. The case of a patient with decreased plasma efavirenz concentrations during concomitant rifabutin therapy is reported. Summary. A 42-year-old Hispanic man newly diagnosed with acquired immune deficiency syndrome (AIDS) and coinfected with aseptic meningitis and disseminated Mycobacterium avium complex (MAC) received efavirenz-based highly active antiretroviral therapy (HAART). When the patient was admitted to the hospital, his medications included enoxaparin, metformin, ganciclovir, clarithromycin, ethambutol, rifampin, pyrazinamide, isoniazid, pyridoxine, trimethoprim-sulfamethoxazole, dexamethasone, and tenofovir-emtricitabine- efavirenz. Rifampin was changed to rifabutin 450 mg daily due to the potential interaction with rifampin and efavirenz. Clarithromycin was replaced with azithromycin for the treatment of MAC infection, and dexamethasone was gradually decreased over three months. The established therapeutic plasma concentration of efavirenz is 1-4 mg/mL. After receiving the standard efavirenz dosage of 600 mg daily, the patient had subtherapeutic plasma efavirenz concentrations. To correct these low concentrations, the patient's efavirenz dosage was increased to 800 mg daily; however, his efavirenz concentrations continued to remain subtherapeutic (two concentrations of 0.58 mg/mL). The patient's viral load decreased slowly while on HAART; however, it only became undetectable 12 days after rifabutin was discontinued. The Drug Interaction Probability Scale demonstrated a probable relationship between the coadministration of rifabutin and the decreased efavirenz concentrations due to the possible induction of efavirenz metabolism by rifabutin. Conclusion. A 42-year-old Hispanic man newly diagnosed with AIDS had subtherapeutic efavirenz levels during concomitant treatment with rifabutin.


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