TABLE 7.
Antiretroviral dose adjustment in patients with hepatic insufficiency
| Medication | Hepatic metabolism | Dose adjustment required in liver failure |
|---|---|---|
| Nucleoside/Nucleotide reverse transcriptase inhibitors | ||
| Abacavir | Yes | No recommended in patients with moderate to severe impairment |
| Child-Pugh score (dose): 5–6 (200 mg twice a day) | ||
| Zidovudine | Yes | No dosage adjustment |
| Lamivudine | No | No dosage adjustment |
| Didanosine | No | No dosage adjustment |
| Stavudine | No | No dosage adjustment |
| Emtricitabine | No | No dosage adjustment |
| Tenofovir | No | No dosage adjustment |
| Non-nucleoside reverse transcriptase inhibitors | ||
| Delavirdine | Yes | No dosage adjustment; use with caution in patients with hepatic impairment |
| Efavirenz | Yes | No dosage adjustment; use with caution in patients with hepatic impairment |
| Nevirapine* | Yes | Avoid initiation in women with a CD4 count >250 cells/μL or in men with a CD4 count >400 cells/μL; ifinitiated, close monitoring isrecommended (every 2 weeks for the first month, then monthly for for 3 months, then every 3 months) |
| Protease inhibitors | ||
| Atazanavir† | Yes | Child-Pugh score (dose): 7–9 (300 mg every day) >9 (not recommended) |
| Fosamprenavir | Yes | Child-Pugh score (dose): 5–8 (700 mg twice a day) 9–12 (not recommended) |
| Indinavir† | Yes | Mild to moderate hepatic insufficiency because of cirrhosis: 600 mg q8h |
| Nelfinavir | Yes | No dosage adjustment; use with caution in patients with hepatic impairment |
| Saquinavir | Yes | No dosage adjustment; use with caution in patients with hepatic impairment |
| Lopinavir/ritonavir | Yes | No dosage adjustment; use with caution in patients with hepatic impairment |
| Tipranavir | Yes | No dosage adjustment; use with caution in patients with hepatic impairment. TPV/RTV is contraindicated in patients with moderate to severe hepatic impairment (Child-Pugh classes B and C) |
| Darunavir Fusion inhibitors | Yes | No data with patients with hepatic impairment; use with caution in this population |
| Enfuvirtide (T-20) | No | No dosage adjustment |
*
Reported cases of severe fulminant hepatitis and death – use not recommended in cases of liver failure;
†
Associated with unconjugated hyperbilirubinemia – refer to product monograph. q8h Every 8 h; TPV/RTV Tipranavir/ritonavir. Data from reference 79