This issue’s Specialist:
Michael Fingerhood, MD, FACP, AAHIVS
Dear HIV Specialist:
I am a registered nurse. I have a question about my HIV medications and I feel as if I am not getting an accurate response from my physician. Two weeks ago I started taking Atripla. On the 13th day of taking the medication I woke up with a head-to-toe rash, hives and extreme pruritus, almost unbearable. My M.D. said that it was the worst rash that she has seen with Atripla. She was certain that it is the Sustiva component of the Atripla, and gave me some samples of Truvada to see if it was the Sustiva component. I discontinued the Atripla and took the Truvada the following day, and I had an even worse outbreak of the rash. This time my lips became swollen, I had hives inside my mouth, and my eyes became swollen. My M.D. said to continue to take the Truvada and to take diphendydramine routinely to reduce the hypersensitivity reaction. I have been taking Benedryl 75 mg every four hours routinely as well as Zyrtec daily, and hydroxizine 50 mg every 4 hours, prednisone 40 mg daily, and I have had two shots of solumedrol IM 125 mg. My M.D. is certain that the rash will disappear but it seems to me that I am having a serious allergic reaction, and not a side effect of a rash! This is so annoying and I do not know what to do because I do not want to have mutations to the medications! Is there any way that allergy testing can be done to find out exactly which component of my HIV regimen that I am allergic to?
Signed, Super Sensitive
Submit your questions for Ask The HIV Specialist to AAHIVM@tpan.com
Dear SS:
The skin rash was undoubtedly related to the efavirenz (Sustiva) component of Atripla. In the original clinical trials, 27% of individuals receiving efavirenz developed a skin rash. However, in less than 1% of patients did the rash lead to blistering or become severe. The usual time to onset of rash is 7 to 14 days after starting efavirenz. The drug remains in the body for many days after stopping, so it is not unusual that the rash and symptoms worsened after you stopped the efavirenz component. The rash related to efavirenz is rarely life threatening and is usually treated with antihistamines, like Benadryl. Most individuals note improvement after a few days and are maintained on the drug. However, we do tell patients to stop efavirenz if there is blistering, significant fever, or a reaction with involvement of mucosal surfaces such as you had with swelling in your mouth and of your eyes. Your severe symptoms were treated appropriately with addition of prednisone and solumedrol. You should not receive efavirenz again, but you certainly can be treated with a regimen containing the other two components of Atripla (Viread and Emtriva, both contained in Truvada).
Michael Fingerhood, MD, FACP, AAHIVS
Associate Professor of Medicine
Johns Hopkins University
Baltimore, MD
