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Managing Drug Interactions in the
Treatment of HIV-Related
Tuberculosis
Introduction
Worldwide, tuberculosis is the most common opportunistic
infection among people with HIV infection. In addition to its frequency, tuberculosis
is also associated with substantial morbidity and mortality. Despite the complexities
of treating two infections requiring multidrug therapy at the same time, antiretroviral
therapy can be life-saving among patients with tuberculosis and advanced HIV
disease. Observational studies in a variety of settings have shown that use
of antiretroviral therapy during tuberculosis treatment results in marked decreases
in the risk of death or other opportunistic infections among persons with tuberculosis
and advanced HIV disease 1, 2.
Concomitant use of treatment for tuberculosis and
antiretroviral therapy is complicated by the adherence challenge of polypharmacy,
overlapping side effect profiles of antituberculosis drugs and antiretroviral
drugs, immune reconstitution inflammatory syndrome, and drug-drug interactions
3. The key interactions, and the focus of this document, are those
between the rifamycin antibiotics and four classes of antiretroviral drugs:
protease inhibitors, non-nucleoside reverse-transcriptase inhibitors [NNRTI],
CCR5-receptor antagonists, and integrase inhibitors 3. Only two
of the currently available antiretroviral drug classes, the nucleoside analogues
(other than zidovudine 4) and enfuvirtide (a parenteral entry inhibitor)
do not have significant interactions with the rifamycins.
The purpose of this summary is to provide the clinician
with updated recommendations for managing the drug-drug interactions that occur
when using antiretroviral therapy during tuberculosis treatment. Changes from
previous versions of these guidelines include: an effort to obtain and summarize
the clinical experience of using specific antiretroviral regimens during tuberculosis
treatment (not just pharmacokinetic data), a table summarizing the clinical
experience with key antiretroviral regimens and providing recommended regimens
(Table 1), and sections on treatment for special populations (young children,
pregnant women, patients with drug-resistant tuberculosis). We include drug-drug
interaction data for antiretroviral drugs that have been approved
or currently
available through expanded access programs in the United States; these recommendations
will be updated as additional antiretroviral drugs progress become available.
Last Reviewed: 05/18/2008 Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
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