A female healthcare worker who received post-exposure prophylaxis with AZT, 3TC and nevirapine suffered a hypersensitivity reaction that resulted in liver failure, requiring a liver transplant 35 days after starting PEP. The case was reported by doctors from Rush-Presbyterian-St Luke's Medical Center in Chicago in today's edition of the Journal of the American Medical Association.
The clinicians believe that liver failure was the consequence of a hypersensitivity reaction to nevirapine, since all liver enzyme levels were normal at the time PEP was started (although the woman was hepatitis B surface antigen positive). Liver failure occurred 27 days after starting PEP, and seven days after treatment was discontinued due to elevated liver enzymes.
A second case of hypersensitivity reaction after the use of nevirapine-based PEP was reported by another Chicago hospital, Northwestern University Medical School, in the same issue of JAMA. In this case a female nurse developed a fever and severe rash within ten days of commencing AZT, 3TC and nevirapine PEP, and despite switching to d4T, 3TC and efavirenz at day 8 due to nausea, fever and headache. A seven day course of prednisone suppressed the reaction, but it re-emerged with equal severity after the prednisone was stopped.
The authors recommend that nevirapine should not be used for PEP until the incidence of severe hypersensitivity reactions is better defined, "particularly if the risk of HIV seroconversion following a needlestick injury (0.3%) is equal to or less than the risk of this life threatening complication".
In London, Camden and Islington Health Authority is changing its policy of providing d4T/3TC and nevirapine in PEP starter packs, following an internal audit of adverse events and in response to the US data. Dr. Paul Benn of the Mortimer Market Centre told the Sixth Annual Conference of the British HIV Association that 9% of those who received nevirapine-based PEP experienced grade 3 or 4 rash or hepatitis. The Health Authority will now provide d4T/3TC and nelfinavir.
Reference
Johnson S, Baraboutis JG, Sha BE, Proia LA, Kessler H. Adverse effects associated with use of nevirapine in HIV postexposure prophylaxis for 2 healthcare workers. JAMA 284 (21): 2722-2723, 2000.