At Elyon Family Clinic and Surgery, we have always emphasized the fact that a cookie-cutter mentality for HIV Post Exposure Prophylaxis (HIV PEP) is not always feasible when prescribing drugs for various patients with a myriad of medical co-morbidities. Our board accredited Family Physician will have to take into account the patient’s medical history, chronic medications, and other factors before deciding upon the best HIV PEP drug regimen for a particular patient. The following case study serves to highlight the importance of considering a patient’s medical history and concurrent medications prior to commencing HIV PEP drugs.
Dyslipidaemia is a common condition amongst Singaporeans, especially with the added temptation of good food and a busy lifestyle. This malady of a raised cholesterol level is common with patients with Type 2 Diabetes, and patients on certain antiretroviral drugs (ART). As part of a holistic management of patients with dyslipidaemia, together with exercise and diet control, statins and/or fibrates are sometimes prescribed and taken on a long term basis to control lipid levels. One of the most serious side effects of these two group of drugs (i.e. statins and fibrates) is muscle breakdown (rhabdomyolysis), resulting in renal damage and serious health consequences.
Case Presentation
A 30 year old gentleman with a high-risk sexual exposure was prescribed the usual HIV PEP regimen of Combivir and Kaletra by an STD clinic in Singapore. The HIV PEP drugs were supposed to be taken daily for a total of 28 days. He presented to me about 2 weeks into his PEP drug regimen with a complaint of muscle weakness and myalgia for the last 2 days. He was otherwise well. He had no recent trauma, and no recent physical exertion of note. He did not have a fever, was a non-smoker, and did not consume any recreational drugs or alcohol.
Physical examination revealed a normal heart rate, blood pressure and respiratory rate. Examination of the heart and lungs were normal, and his abdomen was soft and non-tender. Neurological examination was likewise unremarkable. Of interest, he was on a statin drug (Lovastatin) for his high cholesterol, and had been producing tea-colored urine for the last two days.
A blood test for creatine kinase revealed significant elevation from normal values (21000 U/L). Most patients under normal conditions have creatine kinase below 260 U/L. An extremely elevated creatine kinase level usually points towards rhabdomyolysis, a very serious syndrome.
The patient was subsequently referred to the Accident and Emergency department for admission and treatment.
Discussion
Kaletra contains two protease inhibitors, ritonavir and lopinavir. For HIV PEP, two tablets of Kaletra are taken twice a day (usually in combination with Combivir). It should be remembered that ritonavir not only boosts serum concentrations of other protease inhibitors, but also levels of non-ART drugs. Ritonavir can inhibit the metabolism of other drugs metabolized by certain liver enzymes (cytochrome P-450 enzymes), resulting in excessively high levels of statins.
Therefore, when initiating HIV PEP, it is important for the physician to consider all other concomitant medications to check for potential drug interactions.
A particular caution when prescribing Kaletra is to avoid its use in patients on certain statins for dyslipidaemia. The inhibitory effect of the boosted protease inhibitor results in unacceptably high rates of myopathy and rhabdomyolysis. In the aforementioned case study, the patient was already on Lovastatin for his cholesterol problem. Coadministration of Kaletra and certain statins (Simvastatin, Rosuvastatin and Lovastatin) is contraindicated. A relatively safer statin drug to use with Kaletra is Pitavastatin. Caution should also be exercised when prescribing Kaletra with Pravastatin and Atorvastatin.
HIV PEP Cost at our Clinic
When you have a high risk exposure to HIV, do talk to our board accredited Family Physician concerning HIV Post Exposure Prophylaxis which is recommended for exposures within the last 72 hours. The sooner you commence HIV PEP, the better chance you will have against HIV.
It is also important to discuss with your doctor which HIV PEP regime is more suited to your medico-social history and background. With a holistic approach, we are confident that the best HIV PEP drug regimen will be tailored to your needs.
Our HIV PEP drug cost (complete drug regimen for 1 month duration) starts from $1856. We use the latest PEP drug regimen which is unique to your needs.
HIV PEP consultation starts from $60. This is our usual consultation charge for most consultations for HIV PEP.
A baseline rapid HIV test costs $50. Other baseline tests depend on your medical history. A basic package testing for liver function, kidney function, full blood count, ESR, cholesterol, glucose level, electrolytes, hs-CRP, calcium, phosphate, uric acid level, and UFEME costs only $78.
Total bill is around $2000 only for HIV PEP medications, rapid HIV testing, full baseline tests, and a detailed consultation and assessment.
Please contact our clinic for further information.
