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La importancia de la educación sanitaria del paciente con VIH en tratamiento antirretroviral para evitar interacciones medicamentosas

DOI:10.1016/j.fmc.2015.12.004
Authors:
Antonio V. Bazo-Fariñas at Universidad de Extremadura
Antonio V. Bazo-Fariñas
Guadalupe Alcántara López-Sela
Guadalupe Alcántara López-Sela
Guadalupe Alcántara López-Sela
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Lorena Cano at Universidad Camilo José Cela
Lorena Cano
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Correo de los lectores
FMC. 2016;23(4):253-6 255
Wafa Elgeadi-Saleha,*, Elena Sendagortab
y Elena Ruiz Bravo-Burguillosc
aResidente de Medicina Familiar y Comunitaria. Centro de Salud
Dr. Castroviejo. Madrid. España.
bEspecialista en Dermatología. Hospital Universitario la Paz. Madrid.
España.
cEspecialista en Anatomía patológica. Hospital Universitario la Paz.
Madrid. España.
Correo electrónico: waceleste@hotmail.com;
wafa.elgeadi@salud.madrid.org
Bibliografía
1. Sampaio-Rivitti. Hidroses. En:Dermatología. 3.ª ed. São Paulo: Artes
Médicas; 2008. p. 403-17.
2. Guiotoku MM, Lopes PT, Marques ME, Marques SA, Miot HA. Fox-
Fordyce disease in monozygotic female twins. J Am Acad Dermatol.
2011;65:229-30.
3. Mataix J, Silvestre JF, Niveiro M, Lucas A, Pérez-Crespo M. Perifollicu-
lar xanthomatosis as a key histological finding in Fox-Fordyce disease.
Actas Dermosifiliogr. 2008;99:145-8.
4. Bormate AB, Mc Calmont TH, Leboit PE. Perifollicular xanthomatosis is
the hallmark of axillary Fox-Fordyce disease. Am J Dermatopathol.
2006;28:232.
5. Mireille Chae K, Marschall M, Marschall S. Axillary Fox-Fordyce disea-
se treated with liposuction-assisted curettage. Arch Derma-
tol.2002;138:452-4.
6. González-Ramos J, Alonso-Pacheco ML, Goiburú-Chenú B, Mayor-Ibar-
guren A, Herranz-Pinto P. Successful treatment of refractory pruritic
Fox-Fordyce disease with botulinum toxin type A. Br J Dermatol.
2016;174:458-9.
La importancia de la educación
sanitaria del paciente con VIH
en tratamiento antirretroviral
para evitar interacciones
medicamentosas
Sr. Director:
La importante reacción medicamentosa que ha sufrido una pa-
ciente de nuestras consultas, diagnosticada de VIH y que actual-
mente realiza tratamiento con lopinavir/ritonavir (Kaletra) y abaca-
vir/lamivudina (Kivexa), nos lleva a plantearnos seriamente si
hacemos una buena educación sanitaria con pacientes que utilizan
terapia antirretroviral.
La paciente, de 63 años, consultó por dolor precordial y epigás-
trico irradiado a mandíbula, con cortejo vegetativo acompañante,
intermitente, de unas 4 h de evolución. En el electrocardiograma
realizado se apreciaba BRIHH (conocido) y T negativas en I y
aVL. Al ser un dolor anginoso característico, se solicitó una analíti-
ca, donde se observó una elevación de la troponina I cardíaca 1,25
(rango de normalidad 0-0,06) junto con un leve aumento de la GPT
(69 UI/l) y la GOT (69 UI/l), así como filtrado glomerular leve-
mente disminuido.
Posteriormente fue remitida al cardiólogo de guardia, que reali-
zó ecocardiograma. Presentaba hipocinesia apical grave de seg-
mento distal de septo, cara anterior y cara lateral, con función sistó-
lica global moderadamente deprimida. La paciente fue ingresada en
cardiología, donde se realizó también coronariografía, que descartó
lesiones coronarias asociadas.
A las 24 h de su ingreso en la unidad de cardiología, desarrolla
una marcada cianosis acra (de predominio sobre todo en manos y en
menor medida en miembros inferiores), y se objetiva ausencia de
pulsos radial, braquial y pedio, así como hipotensión arterial, junto
con moderado-intenso dolor en ambas manos, en relación con isque-
mia arterial aguda. La paciente recordó que había tomado un analgé-
sico que contenía ergotamina por una crisis migrañosa que tuvo po-
cas horas antes de consultar el día anterior por dolor torácico.
En el contexto de una interacción entre ergotamina y el trata-
miento antirretroviral, se produjo un síndrome ergotamínico (ergo-
tismo) que explicaría el síndrome descrito previamente y que preci-
só de ingreso en la unidad de cuidados intensivos.
Allí se utilizó tratamiento vasodilatador con calcioantagonistas y
nitratos, junto con anticoagulación con heparina de bajo peso mole-
cular para minimizar el riesgo de trombosis secundaria a vasoes-
pasmo. Tras este tratamiento y la suspensión temporal del trata-
miento antirretroviral se consiguió mejoría de la sintomatología.
Acompañando a este proceso y en relación con la hipoperfusión
sistémica se observó también un deterioro agudo de la función re-
nal con recuperación progresiva también en relación con la mejoría
hemodinámica.
Al alta, ya asintomática, acude a consulta para revisión del pro-
ceso. Presentaba secuelas de la isquemia arterial aguda en dedos de
manos y pies (fig. 1).
La ergotamina y derivados ergotamínicos son muy utilizados ac-
tualmente para el tratamiento de la migraña por su efecto vasocons-
trictor. A veces, bien por su uso crónico o por toxicidad aguda, pue-
den producir lo que conocemos como síndrome ergotamínico, que
cursa con vasoconstricción generalizada y que puede dar lugar a
cuadros isquémicos a consecuencia del vasoespasmo generalizado
(dolor torácico, crisis anginosas, mialgias, isquemia arterial, etc.).
Menos común es la afectación aórtica, mesentérica, renal, corona-
ria, retininana o carotídea.
Los inhibidores de la proteasa, como el ritonavir, presentan un
gran riesgo de interacción con muchas medicaciones al funcionar
como inhibidor del citocromo CYP450 por unión competitiva re-
versible a la insoenzima CYP3A41.
El uso combinado de inhibidores de la proteasa junto con ergo-
tamina o derivados que son metabolizados por esta vía puede llegar
a incrementar sus concentraciones plasmáticas y producir toxici-
dad, y provocar, como en este caso, un síndrome erogotamínico2.
Como alternativa al tratamiento de la migraña en pacientes se
recomienda el uso de sumatriptán y paracetamol3.
Figura 1. Esfacelos residuales secundarios a la isquemia.
Document downloaded from http://www.elsevier.es, day 27/01/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from http://www.elsevier.es, day 27/01/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Correo de los lectores
256 FMC. 2016;23(4):253-6
La primera descripción de un síndrome ergotamínico en relación
con la interacción de los inhibidores de la proteasa (fundamental-
mente ritonavir) y la ergotamina fue en 1997. Actualmente no exis-
te mucha bibliografía al respecto4.
En una revisión de 17 casos similares se concluye, por un lado,
que en la mayoría de los casos, la ergotamina no tenía prescripción
médica (automedicación) y, por otro, que el comienzo de la sinto-
matología fue, por término medio, 4 días posterior al inicio del tra-
tamiento con ergotomina5.
Es fundamental que desde atención primaria estemos alerta ante
las posibles interacciones de los fármacos antirretrovirales con
otras medicaciones y se lo recordemos periódicamente a los pa-
cientes, así como las contraindicaciones y riesgos que conlleva la
terapia antirretroviral6.
Antonio V. Bazo Fariñas*, Guadalupe Alcántara López-
Sela y Lorena E. Cano Lucas
Médicos de familia. CS Valdepasillas (SES). Badajoz. España.
*Correo electrónico: abazofar@gmail.com
Bibliografía
1. Dresser GK, Spence JD, Bailey DG. Pharmacokinetic-pharmacodynamic
consequences and clinical relevance of cytochrome P450 3A4 inhibition.
Clin Pharmacokinet. 2000;38:41-57.
2. Morales Conejo M, Moreno Cuerda VJ, Abellán Martínez J, Rubio R.
Efectos secundarios graves derivados de las interacciones medicamento-
sas del tratamiento antirretroviral. Rev Clin Esp. 2008;208:557-60.
3. Eadie MJ. Clinically significant drug interactions with agents specific for
migraine attacks. CNS Drugs. 2001;15:105-18. Review.
4. Caballero-Granado FJ, Viciana P, Cordero E, Gómez-Vera MJ, del Nozal
M, López-Cortés LF. Ergotism related to concurrent administration of
ergotamine tartrate and ritonavir in an AIDS patient. Antimicrob Agents
Chemother. 1997;41:1207.
5. Finn BC, Vadalá S, Meraldi A, Bruetman JE, Martinez JV, Young P. Er-
gotismo y HIV. Revista Medicina (Buenos Aires). 2013;73;346-8.
6. Manzardo C, Tuset M, Miró JM, Gatell JM. Interacciones graves o po-
tencialmente letales entre antirretrovirales y otros medicamentos. En-
ferm Infecc Microbiol Clin. 2015;33.e15-e30.
Document downloaded from http://www.elsevier.es, day 27/01/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from http://www.elsevier.es, day 27/01/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
ResearchGate has not been able to resolve any citations for this publication.
[Ergotism and HIV]
Article
Full-text available
Ergotism is a complication of acute intoxication and/or chronic abuse of ergot derivatives. It expresses itself through a vasomotor syndrome with peripheral vascular disease which frequently involves extremities. We report four cases of HIV-1 infected patients treated with antiretroviral drugs including boosted-protease inhibitors who had self-treated themselves with ergotamine. They developed peripheral vascular disease symptoms and their pulses where diminished or absent in the physical examination. Arterial Doppler confirmed diffused arterial spasm in two of them. Ergotism following ergotamine-protease inhibitors association was diagnosed. Patients were treated through the discontinuity of involved drugs (protease inhibitors and ergotamine), calcium blockers; antithrombotic prophylaxis with enoxaparine, antiaggregant therapy with acetylsalicylic acid, and one of them received pentoxifylline and vasodilator prostaglandins infusion, with amelioration of the symptoms. We discuss the clinical presentation of this drug interaction, difficult to diagnose properly without a strong suspicion of its existence.
Ergotism related to concurrent administration of ergotamine tartrate and ritonavir in an AIDS patient
Article
Full-text available
  • Jun 1997
Successful treatmeant of refractory pruritic Fox-Fordyce disease with botulinum Toxin Type A
Article
Fox-Fordyce disease (FFD), characterized by intensely pruritic papules in apocrine gland-bearing regions, is a rare disorder for which there is currently no definitive treatment or known cure1.A 52 year-old menopausal woman with a history of hypothyroidism under treatment with oral levothyroxin, presented with a twenty-five-year history of multiple, intensely pruritic firm papules in both axillae with associated hypohidrosis. Her pruritus was not alleviated by scratching, but it was by applying cold water several times a day. Her lesions worsened after laser hair removal five years earlier.This article is protected by copyright. All rights reserved.
[Severe or life-threatening interactions between antiretrovirals and non-HIV drugs.]
Article
Highly active antiretroviral therapy has helped to improved control of the HIV infection, and has led to a progressively older population with the infection having a life expectancy quite similar to that of the general population. On the other hand, it is also known that HIV infection, even in patients with undetectable viral loads and good immunity, carries an increased cardiovascular risk, as well as an increased incidence of certain cancers. Therefore, the majority of HIV-infected patients receive several drugs (either prescribed by the physician or self-administered) combined with antiretrovirals. This article reviews the interactions between antiretrovirals and other drugs that can cause significant damage to patients, or even be life-threatening and of whom clinicians, especially those not directly treating HIV-infected patients, should be aware. A review is also presented on the implications of interactions between antiretrovirals and other drugs in special situations, such as the co-administration with cytostatics, immunesuppressants used in solid organ transplantation, or patients receiving new treatments for hepatitisC. Generally, combinations with two nucleos(t)ide reverse transcriptase inhibitors and raltegravir (or in the near future, dolutegravir) are those with less potential for clinically significant interactions. Copyright © 2013 Elsevier España, S.L.U. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.
Interacciones graves o potencialmente letales entre antirretrovirales y otros medicamentos
Article
Highly active antiretroviral therapy has helped to improved control of the HIV infection, and has led to a progressively older population with the infection having a life expectancy quite similar to that of the general population. On the other hand, it is also known that HIV infection, even in patients with undetectable viral loads and good immunity, carries an increased cardiovascular risk, as well as an increased incidence of certain cancers. Therefore, the majority of HIV-infected patients receive several drugs (either prescribed by the physician or self-administered) combined with antiretrovirals. This article reviews the interactions between antiretrovirals and other drugs that can cause significant damage to patients, or even be life-threatening and of whom clinicians, especially those not directly treating HIV-infected patients, should be aware. A review is also presented on the implications of interactions between antiretrovirals and other drugs in special situations, such as the co-administration with cytostatics, immunesuppressants used in solid organ transplantation, or patients receiving new treatments for hepatitis C. Generally, combinations with two nucleos(t)ide reverse transcriptase inhibitors and raltegravir (or in the near future, dolutegravir) are those with less potential for clinically significant interactions.
Efectos secundarios graves derivados de las interacciones medicamentosas del tratamiento antirretroviral
Article
  • Nov 2008
Background and aim Antiretroviral drugs can cause drug interactions. Material and methods Three clinical cases are described regarding HIV-infected patients in which a clinically relevant adverse effect occurred due to a pharmacokinetic interaction. Results Case 1: A 43-year old woman being treated with tenofovir DF, emtricitabine and lopinavir/ritonavir who presents ischemia in both upper extremities following an ergotamine syndrome. Case 2: A 54-year old man being treated with zidovudine, lamivudine and lopinavir/ritonavir who presents Cushing syndrome following to use of inhaled fluticasone. Case 3: A 45-year old man being treated with tenofovir DF, emtricitabine and atazanavir/ritonavir who presents a virological failure as consequence of concomitant use of omeprazole. Conclusions Potential drug interactions must be considered when other concomitant drugs are used with antiretroviral therapy especially when one of these is a P 450 cytochrome enzymatic inductor or inhibitor.
Perifollicular Xanthomatosis is the Hallmark of Axillary Fox-Fordyce Disease
Article
Background: Fox-Fordyce disease (FFD) or apocrine miliaria is a rare condition with features that are characteristic clinically but not histopathologically. It is traditionally described as a condition that shows infundibular plugging, acanthosis, parakeratosis, spongiosis, and a nonspecific infiltrate. The so-called retention vesicle, which reputed]), involves the apocrine duct, is often difficult to find. Recently, 4 uncontrolled observations were described (infundibular dyskeratotic cells, vacuolar alteration, cornoid lamella-like parakeratosis, and perifollicular foamy macrophages). In this study, we evaluated both established and new histopathologic criteria for the diagnosis of FFD and searched for other meaningful findings. Observations: Most established features were observed in both patients with FFD and control patients. All cases occurred during 1995 through 2005. No unequivocal retention vesicle was identifiable in any case. Infundibular vacuolar change and cornoid lamella-like parakeratosis were not corroborated as being diagnostically meaningful. Few dyskeratotic cells were seen in some patients with FFD and in control patients. Perifollicular foam cells were noted in most patients with FFD but not among control patients. These cells expressed CD68 but lacked expression of carcinoembryonic antigen, gross cystic disease fluid protein 15, and periodic acid-Schiff with diastase digestion. Perifollicular mucin, fibrosis, and mast cells in the infiltrate were also observed. Conclusions: The established histopathologic attributes of FFD are nonspecific, and a retention vesicle is difficult to find even in level sections. In contrast, perifollicular foam cells are a distinct, relatively consistent, and specific feature of FFD. We contend that perifollicular foam cells represent a useful hallmark of FFD.
Fox-Fordyce disease in monozygotic female twins
Article
  • Jul 2011
Dresser GK, Spence JD, Bailey DGPharmacokinetic-pharmacodynamic consequences and clinical relevance of cytochrome P450 3A4 inhibition. Clin Pharmacokinet 38: 41-57
Article
  • Feb 2000
Drug interactions occur when the efficacy or toxicity of a medication is changed by administration of another substance. Pharmacokinetic interactions often occur as a result of a change in drug metabolism. Cytochrome P450 (CYP) 3A4 oxidises a broad spectrum of drugs by a number of metabolic processes. The location of CYP3A4 in the small bowel and liver permits an effect on both presystemic and systemic drug disposition. Some interactions with CYP3A4 inhibitors may also involve inhibition of P-glycoprotein. Clinically important CYP3A4 inhibitors include itraconazole, ketoconazole, clarithromycin, erythromycin, nefazodone, ritonavir and grapefruit juice. Torsades de pointes, a life-threatening ventricular arrhythmia associated with QT prolongation, can occur when these inhibitors are coadministered with terfenadine, astemizole, cisapride or pimozide. Rhabdomyolysis has been associated with the coadministration of some 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors ('statins') and CYP3A4 inhibitors. Symptomatic hypotension may occur when CYP3A4 inhibitors are given with some dihydropyridine calcium antagonists, as well with the phosphodiesterase inhibitor sildenafil. Excessive sedation can result from concomitant administration of benzodiazepine (midazolam, triazolam, alprazolam or diazepam) or nonbenzodiazepine (zopiclone and buspirone) hypnosedatives with CYP3A4 inhibitors. Ataxia can occur with carbamazepine, and ergotism with ergotamine, following the addition of a CYP3A4 inhibitor. Beneficial drug interactions can occur. Administration of a CYP3A4 inhibitor with cyclosporin may allow reduction of the dosage and cost of the immunosuppressant. Certain HIV protease inhibitors, e.g. saquinavir, have low oral bioavailability that can be profoundly increased by the addition of ritonavir. The clinical importance of any drug interaction depends on factors that are drug-, patient- and administration-related. Generally, a doubling or more in plasma drug concentration has the potential for enhanced adverse or beneficial drug response. Less pronounced pharmacokinetic interactions may still be clinically important for drugs with a steep concentration-response relationship or narrow therapeutic index. In most cases, the extent of drug interaction varies markedly among individuals; this is likely to be dependent on interindividual differences in CYP3A4 tissue content, pre-existing medical conditions and, possibly, age. Interactions may occur under single dose conditions or only at steady state. The pharmacodynamic consequences may or may not closely follow pharmacokinetic changes. Drug interactions may be most apparent when patients are stabilised on the affected drug and the CYP3A4 inhibitor is then added to the regimen. Temporal relationships between the administration of the drug and CYP3A4 inhibitor may be important in determining the extent of the interaction.
Clinically Significant Drug Interactions with Agents Specific For Migraine Attacks
Article
  • Feb 2001
The drugs which provide specific relief from migraine attacks, the ergopeptides (ergotamine and dihydroergotamine) and the various ‘triptans’ (notably sumatriptan), are often prescribed for persons already taking various migraine preventative agents, and sometimes drugs for other indications. As aresult, migraine-specific drugs may become involved in drug-drug interactions. The migraine-specific drugs all act as agonists at certain subclasses of serotonin (5-hydroxytryptamine; 5-HT) receptor, particularly those of the 5-HT1D subtype, and produce vasoconstriction through these receptor-mediated mechanisms. The oral bioavailabilities of these drugs, particularly those of the ergopeptides, are often incomplete, due to extensive presystemic metabolism. As a result, if migraine-specific agents are coadministered with drugs with vasoconstrictive properties, or with drugs which inhibit the metabolism of the migraine-specific agents, there is a risk of interactions occurring which produce manifestations of excessive vasoconstriction. This can also occur through pharmacodynamic mechanisms, as when ergopeptides or triptans are coadministered with methysergide or propranolol (although a pharmacokinetic element may apply in relation to the latter interaction), or if one migraine-specific agent is used shortly after another. When ergopeptide metabolism is inhibited by the presence of macrolide anti-bacterials, particularly troleandomycin and erythromycin, the resultant interaction can produce ergotism, sometimes leading to gangrene. Similar pharmacokinetic mechanisms, with their vasoconstrictive consequences, probably apply to combination of the ergopeptides with HIV protease inhibitors (indinavir and ritonavir), heparin, cyclosporin or tacrolimus. Inhibition of triptan metabolism by monoamine oxidase A inhibitors, e.g. moclobemide, may raise circulating triptan concentrations, although this does not yet seem to have led to reported clinical problems. Caffeine may cause increased plasma ergotamine concentrations through an as yet inadequately defined pharmacokinetic interaction. However, a direct anti-migraine effect of caffeine may contribute to the claimed increased efficacy of ergotamine-caffeine combinations in relieving migraine attacks. Serotonin syndromes have been reported as probable pharmacodynamic consequences of the use of ergots or triptans in persons taking serotonin reuptake inhibitors. There have been two reports of involuntary movement disorders when sumatriptan has been used by patients already taking loxapine. Nearly all the clinically important interactions between the ergopeptide antimigraine agents and currently marketed drugs are likely to have already come to notice. In contrast, new interactions involving the triptans are likely to be recognised as additional members of this family of drugs, with their different patterns of metabolism and pharmacokinetics, are marketed.