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

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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.
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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.
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