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Clinical and genetic factors associated with increased risk of severe liver toxicity in a monocentric cohort of HIV positive patients receiving nevirapine-based antiretroviral therapy

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BMC Infectious Diseases201818:556

https://doi.org/10.1186/s12879-018-3462-5

  • Received: 13 December 2017
  • Accepted: 31 October 2018
  • Published:
Open Peer Review reports

Abstract

Background

Nevirapine has been used as antiretroviral agent since early ‘90. Although nevirapine is not currently recommended in initial anti-HIV regimens, its use remains consistent in a certain number of HIV-1-positive subjects. Thus, our aim was to determine clinical and genetic factors involved in the development of severe nevirapine induced liver toxicity.

Methods

We retrospectively analyzed all HIV positive patients who were followed at the Infectious Diseases Unit, DIBIC Luigi Sacco, University of Milan from May 2011 to December 2015. All patients treated with nevirapine who underwent a genotyping for the functional variants mapping into ABCB1, CYP2B6, CYP3A4 and CYP3A5 genes were included in the analysis. Severe hepatotoxicity was defined as ACTG grade 3–4 AST/ALT increase during the first three months of nevirapine treatment. The causality assessment between NVP exposure and drug-induced liver injury was performed by using the updated Roussel Uclaf Causality Assessment Methods. Hardy Weinberg equilibrium was tested by χ2 test. A multivariable logistic regression model was constructed using a backward elimination method.

Results

Three hundred and sixty-two patients were included in the analysis, of which 8 (2.2%) experienced a severe liver toxicity. We observed no differences between patients with and without liver toxicity as regards gender, ethnicity, age and immune-virological status. A higher prevalence of HCV coinfection (75.0% vs 30.2%; p = .0013) and higher baseline AST (58 IU/L vs 26 IU/L; p = 0.041) and ALT (82 IU/L vs 27 IU/L; p = 0.047) median levels were observed in patients with liver toxicity vs those without toxicity. The genotypes CT/TT at ABCB1 rs1045642 single nucleotide polymorphism (SNP), showed a protective effect for liver toxicity when compared with genotype CC (OR = 0.18, 95%CI 0.04–0.76; p = 0.020) in univariate analysis. In the multivariate model, HCV coinfection was independently associated with higher risk of developing liver toxicity (aOR = 8.00, 95%CI 1.27–50.29; p = 0.027), whereas ABCB1 rs1045642 CT/TT genotypes (aOR = 0.10, 95%CI 0.02–0.47; p = 0.004) was associated with a lower risk.

Conclusions

According to our findings HCV coinfection and ABCB1 rs1045642 SNP represent independent determinants of severe liver toxicity related to nevirapine. This genetic evaluation could be included as toxicity assessment in HIV-1-positive subjects treated with nevirapine.

Keywords

  • Nevirapine
  • Pharmacogenetic
  • Hepatotoxicity
  • ABCB1

Background

Nevirapine (NVP) is a potent non-nucleoside reverse transcriptase inhibitor widely prescribed in low-income countries for HIV treatment and prevention of mother-to-child transmission of HIV [1]. In high-resource countries, NVP is no longer included among antiretrovirals recommended for initial antiretroviral treatment (ART), although it still remains a valid component of regimens used as ART simplification strategy due to its high efficacy, good metabolic profile, convenience, and low cost [24].

Although generally well tolerated and effective, some individuals exposed to NVP develop in the short-term hypersensitivity reactions which can manifest as hepatotoxicity and/or severe cutaneous adverse reactions [5]. Hepatotoxicity, in particular, has been reported more commonly with NVP than with other antiretroviral drugs [6, 7]. Higher baseline and nadir CD4 cell count have been found to independently influence the risk of NVP-related adverse reactions and the use of NVP in naive women (with CD4 > 250 cells/uL) and males (with CD4 > 400 cells/uL) is disallowed [8]. The role of the immune system, i.e. higher CD4 cells count, in the development of NVP induced skin and liver toxicity is corroborated by the higher incidence of these events in HIV negative patients receiving NVP as a component of post exposure prophylaxis [5]. Nevertheless, when NVP is used in ART-experienced patients with a controlled viremia the risk of development hepatic or cutaneous adverse events significantly decrease and there is no evident association with CD4 cell count [911].

A series of demographic and clinical factors have been found to correlate with an increased risk of NVP-toxicity. In particular, risk factors for ALT and AST elevations during NVP therapy included alteration of liver enzymes before NVP start, co-infection with hepatitis B or hepatitis C viruses, female gender and low body weight [6, 12].

A number of studies have also investigated the possible predictive role of genetic polymorphisms of CYP enzymes or drug-transporters involved in NVP metabolism in predisposing to NVP-related adverse effects. NVP is metabolized by cytochrome P450 enzymes CYP2B6 and CYP3A4 with a minor contribution from CYP3A5 [13]. Single nucleotide polymorphisms (SNPs) have been found to impact NVP pharmacokinetics in ethnic mix populations [1416]. The genotype TT (c.516/rs3745274) in the CYP2B6 gene, in particular, has been associated with higher plasma concentrations of NVP and its possible role in increasing the risk of hepatotoxicity has been hypothesized [14]. However, there is contrasting evidence of interactions between the presence of variant alleles of CYP2B6 and the development of NVP-induced hepatotoxicity [1719]. The role of CYP3A4 and CYP3A5 variants in determining NVP plasma concentration and the development of liver toxicity is more controversial, with only one report of association between CYP3A5 variants and transaminase values in African patients exposed to NVP [20]. Moreover, although effects of the efflux transporter P-glycoprotein encoded by the ATP Binding Cassette Subfamily B Member 1 (ABCB1) gene on NVP pharmacokinetics remains controversial, two studies have found a protective effect of ABCB1 c.3435 T allele against NVP-related hepatotoxicity [19, 20].

The majority of the studies that evaluated the correlation between pharmacogenetic profiles and NVP-related hepatotoxicity have been performed mainly on African population. However, genetic variant frequencies can differ markedly between different populations and only few data are available on the mentioned pharmacogenetic profiles in non-African populations.

With this in mind, we assessed clinical and pharmacogenetic factors associated with the risk of severe NVP induced liver toxicity in a population of HIV-positive patients attending a clinical center in Italy.

Methods

This study was conducted on a cohort of adult HIV-positive patients attending the Infectious Diseases Unit, DIBIC Luigi Sacco, University of Milan between May 1 2011 and December 31 2015. Patients who have ever received or were receiving a NVP-containing cART at our clinical center were eligible for the analysis.

Patient’s demographic (age, gender, and ethnicity), epidemiological (HIV acquisition risk) and clinical (CDC stage, body mass index, coinfections, previous and current antiretroviral regimens, immune-virological and hemato-biochemical parameters) data registered during medical visits (on average every three months) are routinely collected in a structured database, allowing the use of the database for clinical, epidemiological or therapeutic studies.

Severe hepatotoxicity was defined as ACTG grade 3–4 AST and/or ALT increase (AST or ALT elevation above 5 time the upper reference limit) during the first three months of nevirapine treatment. The causality assessment between NVP exposure and drug-induced liver injury was performed by using the updated Roussel Uclaf Causality Assessment Methods (RUCAM) [21]. According to the RUCAM, patients were firstly assessed for hepatocellular, cholestatic or mixed liver injury. Subsequently, the score was applied and single cases of NVP-induced liver injury were classified accordingly to the RUCAM total score interpretation and causality grading: ≤0, excluded; 1–2, unlikely; 3–5, possible; 6–8, probable and ≥ 9 highly probable [21].

All patients who met the inclusion criteria underwent a genotyping for the functional variants mapping in ABCB1 (c.3435/rs1045642), CYP2B6 (c.516/rs3745274), CYP3A5 (*3/rs776746) and CYP3A4 (*22/rs35599367) genes. Genomic DNA was isolated from peripheral blood cells using an automatic DNA extraction system (Maxwell® 16 System, Promega) according to the manufacturer’s instructions. All genotypes were determined by Real-Time PCR, using a panel of LightSNiP from TIB-MolBiol (assays based on SimpleProbe®). At the end of the amplification a melting curve analysis was performed (LightCycler 480, Roche).

Statistical analysis

Baseline clinical characteristics and genotypes of the two groups of interest, i.e. patients who developed severe hepatotoxicity and those who did not, were compared using the χ2 or Fisher’s exact test for categorical variables and the Mann-Whitney test for continuous variables.

Hardy Weinberg equilibrium was tested by χ2 test.

The association of clinical and genotypic variables with the development of sever liver toxicity was tested by means of a univariate logistic regression model, and all variables were incorporated into a multivariate logistic regression model with a backward elimination method. Statistical significance was defined at 2-sided P value < 0.05. The risks were expressed as adjusted odds ratios (aOR) with relative confidence intervals (95% CI). To perform statistical analysis we used the SAS software version 9.3.

The study was reviewed and approved by our ethics committee (Comitato Etico Interaziendale, Milano area 1); all subjects signed a dedicated informed consent.

Results

A total of 362 patients were included in the analysis. Most of them were ART-experienced at the time of initiation of NVP-containing regimen, whereas a minority (16.1%) were ART-naïve. Overall 8 (2.2%) patients experienced a severe liver toxicity during the first three months from NVP initiation. Table 1 shows the comparison of patients who experienced a severe hepatotoxicity and those who did not. There was no significant difference as regards gender, ethnicity, age and baseline immune-virological status between the two groups although females showed a trend towards a higher frequency of NVP-induced hepatotoxicity (75.0% vs 35.9%; p = 0.055). Conversely, patients who developed severe hepatotoxicity were more frequently HCV-coinfected (75.0% vs 30.2%: p = 0.013), showed higher baseline AST and ALT median levels (58 IU/L vs 26 IU/L p = 0.041, 82 IU/L vs 27 IU/L p = 0.047, respectively), and a lower median baseline body mass index value (19.9 kg/m2 vs 22.6 kg/m2; p = 0.017).
Table 1

Baseline characteristics

 

Total

n = 362

Hepatotoxicity

n = 8

No hepatotoxicity

n = 354

p*

Age, median (IQR)

38.5 (33.7–45.8)

39.6 (32.7–40.7)

38.5 (33.8–45.9)

0.479

Female, n (%)

133 (36.7)

6 (75.0)

127 (35.9)

0.055

Naïve patients, n (%)

58 (16.0)

1 (12.5)

57 (16.1)

0.783

Risk group, n (%)

 Eterosexual

181 (50.0)

4 (50.0)

177 (50.0)

0.213

 MSM

83 (22.9)

0 (0.0)

83 (23.5)

 IVDUs

84 (23.2)

4 (50.0)

80 (22.6)

 Others

14 (3.9)

0 (0.0)

14 (3.9)

Caucasian, n (%)

330 (91.1)

7 (87.5)

323 (91.2)

0.527

BMI, median (IQR)

22.4 (20.5–24.5)

19.9 (18.3–22.0)

22.6 (20.6–24.5)

0.017

AIDS, n (%)

63 (17.4)

1 (12.5)

62 (17.5)

0.999

CD4+/mL, median (IQR)

436 (306–593)

555 (479–611)

433 (300–592)

0.157

HIV-RNA log10 cp/mL,median (IQR)

1.75 (0.00–4.09)

0.00 (0.00–2.16)

1.79 (0.00–4.10)

0.229

HCV coinfection, n (%)

131 (31.2)

6 (75.5)

107 (30.2)

0.013

HBV coinfection, n (%)

21 (5.8)

1 (12.5)

20 (5.65)

0.383

AST U/L, median (IQR)

26 (20–38)

58 (29–92)

26 (20–37)

0.041

ALT U/L, median (IQR)

28 (18–50)

82 (37–122)

27 (18–49)

0.047

ARV backbone, n (%)

 ABC

32 (8.8)

1 (12.5)

31 (8.8)

0.311

 AZT/DDI/D4T

223 (61.6)

7 (87.5)

216 (61.0)

 TDF

86 (23.7)

0 (0.0)

86 (24.3)

 Others

21 (5.8)

0 (0.0)

21 (5.9)

Abbreviations: n number, yrs. years, IQR Inter Quartile Range, MSM Man how have sex with man, IVDUs Intra venous drug users, BMI Body Mass Index, cps copies, ABC abacavir, TDF tenofovir diproxil fumarate. *p-values are for χ2 or Fisher’s exact test and Mann-Whitney test

According to RUCAM, the 8 cases of NVP-induced liver toxicity were classified as hepatocellular injury and the likelihood of NVP-induced liver toxicity resulted possible for 3 patients and probable for 5 patients as shown in Table 2. A brief narration for each of the 8 cases is reported in Table 3.
Table 2

Updated RUCAM for the nevirapine-induced hepatocellular injury with the total scores for each patient

RUCAM items

Pt 1

Pt 2

Pt 3

Pt 4

Pt 5

Pt 6

Pt 7

Pt 8

1. Time to onset from the beginning of the drug

• 5–90 days (rechallenge: 1–15 days) (+ 2)

• < 5 or > 90 days (rechallenge: > 15 days) (+ 1)

Alternative: Time to onset from cessation of the drug

• ≤15 days (except for slowly metabolized chemicals: > 15 days) (+ 1)

+ 2

+ 2

+ 2

+ 2

+ 2

+ 2

+ 2

+ 2

2. Course of ALT after cessation of the drug

• Percentage difference between ALT peak and N

• Decrease ≥50% within 8 days (+ 3)

• Decrease ≥50% within 30 days (+ 2)

• No information or continued drug use (0)

• Decrease ≥50% after the 30th day (0)

• Decrease < 50% after the 30th day or recurrent increase (− 2)

+ 2

+ 2

+ 2

+ 2

+ 2

+ 3

+ 2

0

3. Risk factors

• Alcohol use (current drinks/d: > 2 for women, > 3 for men) (+ 1)

• Alcohol use (current drinks/d: ≤2 for women, ≤3 for men) (0)

• Age ≥ 55 years (+ 1)

• Age < 55 years (0)

0

0

+ 1

0

+ 1

+ 0

0

0

4. Concomitant drug(s)

• None or no information (0)

• Concomitant drug/herb with incompatible time to onset (0)

• Concomitant drug/herb with compatible or suggestive time to onset (1)

• Concomitant drug/herb known as hepatotoxin and with compatible or suggestive time to onset delete marking right side above (− 2)

• Concomitant drug/herb with evidence for its role in this case (positive rechallenge or validated test) (− 3)

0

0

− 2

0

0

0

0

0

5. Search for alternative causes Tick if negative Tick if not done

Group I (7 causes)

• HAV: Anti-HAV-IgM

• Hepatobiliary sonography / colour Doppler

• HCV: Anti-HCV, HCV-RNA

• HEV: Anti-HEV-IgM, anti-HEV-IgG, HEV-RNA

• Hepatobiliary sonography/colour Doppler sonography of liver vessels/endosonography/CT/MRC

• Alcoholism (AST/ALT ≥2)

• Acute recent hypotension history (particularly if underlying heart disease)

Group II (5 causes)

• Complications of underlying disease(s) such as sepsis, metastatic malignancy, autoimmune hepatitis, chronic hepatitis B or C, primary biliary cholangitis or sclerosing cholangitis, genetic liverdiseases

• Infection suggested by PCR and titer change for

- CMV (anti-CMV-IgM, anti-CMV-IgG)

- EBV (anti-EBV-IgM, anti-EBV-IgG)

- HSV (anti-HSV-IgM, anti-HSV-IgG)

- VZV (anti-VZV-IgM, anti-VZV-IgG)

Evaluation of groups I and II

• All causes-groups I and II—reasonably ruled out (+ 2)

• The 7 causes of group I ruled out (+ 1)

• 6 or 5 causes of group I ruled out (0)

• Less than 5 causes of group I ruled out (− 2)

• Alternative cause highly probable (− 3)

0

0

0

0

−2

+ 1

0

0

6. Previous hepatotoxicity of the drug

• Reaction labelled in the product characteristics (+ 2)

• Reaction published but unlabelled (+ 1)

• Reaction unknown (0)

+ 2

+ 2

+ 2

+ 2

+ 2

+ 2

+ 2

+ 2

7. Response to unintentional reexposure

• Doubling of ALT with the drug/herb alone, provided ALT below 5 N before reexposure (+3)

• Doubling of ALT with the drug(s)/herb(s) already given at the time of first reaction (+ 1)

• Increase of ALT but less than N in the same conditions as for the first administration (−2)

• Other situations (0)

0

0

0

0

0

0

0

0

Total

+ 6

+ 6

+ 5

+ 6

+ 5

+ 8

+ 6

+ 4

Abbreviations: pt. Patient, ALT Alanine aminotransferase, AST Aspartate aminotransferase, CMV Cytomegalovirus, CT Computer tomography, EBV Epstein Barr virus, HAV Hepatitis A virus, HBc Hepatitis B core, HBsAg Hepatitis B antigen, HBV Hepatitis B virus, HCV Hepatitis C virus, HEV Hepatitis E virus, HSV Herpes simplex virus, MRC Magnetic resonance cholangiography, N upper limit of the normal range, RUCAM Roussel Uclaf Causality Assessment Method, VZV Varicella zoster virus

Total score and resulting causality grading: ≤0, excluded; 1–2, unlikely; 3–5, possible; 6–8, probable; and ≥ 9, highly probable

Table 3

Clinical characteristics of the 8 cases of NVP-induced liver injury. *HLAB5701 tested absent

 

Pt 1

Pt 2

Pt 3

Pt 4

Pt 5

Pt 6

Pt 7

Pt 8

HCV coinfection

no

yes

yes

yes

yes

no

yes

yes

ARV status

Experienced

Experienced

Experienced

Experienced

Naive

Experienced

Experienced

Experienced

Concomitant ARV

d4T + 3TC

d4T + 3TC

ABC* + 3TC

AZT + 3TC

AZT + 3TC

d4T + ddi

AZT + 3TC

d4T + ddi

NVP exposure before treatment interruption (days)

28

61

29

28

58

28

50

38

Concomitant medication

none

none

Vitamin D and folinic acid

none

Phenobarbital and alprazolam

none

None

Folinic acid

Symptoms

Nausea and severe weakness

none

Nausea

none

Weakness

none

Nausea

None

Required hospitalization

yes

no

yes

no

no

no

no

no

Outcome

Recovered without sequelae

Recovered without sequelae

Recovered without sequelae

Recovered without sequelae

Recovered without sequelae

Recovered without sequelae

Recovered without sequelae

Recovered without sequelae

RUCAM

Probable

Probable

Possible

Probable

Possible

Probable

Probable

Possible

Abbreviations: Pt Patient, HCV Hepatitis C virus, ARV Antiretroviral, d4T Stavudine, 3TC Lamivudine, ABC Abacavir, AZT Zidovudine, ddi Didanosine, RUCAM Roussel Uclaf Causality Assessment Method

Distribution of different genotypes of ABCB1 rs1045642, CYP2B6 rs3745274 and CYP3A4/A5 combined are shown in Table 4. A statistical significant difference was observed in patient with and without NVP-induced hepatotoxicity according to ABCB1 rs1045642 genotypes (p = 0.019).
Table 4

Disposition of polymorphisms involved in nevirapine metabolism

 

Total

Hepatotoxicity

No hepatotoxicity

p*

n = 362

n = 8

n = 354

ABCB1 c.3435/rs1045642, n (%)

   

0.019

 CC

86 (23.8)

5 (5.8)

81 (94.2)

 

 CT

178 (49.2)

1 (0.6)

177 (99.4)

 

 TT

98 (27.0)

2 (2.0)

96 (98.0)

 

CYP2B6 c.516/rs3745274, n (%)

   

0.706

 GG

196 (54.1)

6 (3.1)

190 (96.9)

 

 GT

141 (39.0)

2 (1.4)

139 (98.6)

 

 TT

25 (6.9)

0 (0.0)

25 (100.0)

 

CYP3A4/A5 **, n (%)

   

0.602

Extensive

58 (16.1)

0 (0.0)

58 (100.0)

 

Intermediate

270 (74.5)

8 (3.0)

262 (97.0)

 

Poor

25 (6.9)

0 (0.0)

25 (100.0)

 

 nd

9 (2.5)

0 (0.0)

9 (100.0)

 

Abbreviations: n number, nd not determined, ABCB ATP Binding Cassette Subfamily B, CYP Cytochrome P450 enzyme

*χ2 test ** CYP3A4*22/rs35599367 and CYP3A5*3/rs776746 combined genotypes for comprehensive functional evaluation [33, 34]

In univariate analysis (Table 5), male gender (OR = 0.19 95%CI 0.04–0.94; p = 0.042), HCV coinfection (OR = 6.93 95%CI 1.38–34.87; p = 0.019), AST (OR = 1.02, 95%CI 1.01–1.03; p = 0.008) and ALT (OR = 1.01, 95%CI 1.00–1.02; p = 0.015) median level at the beginning of NVP have been associated with an increased risk of severe NVP-induced liver toxicity. On the other hand, genotypes CT/TT of ABCB1 rs1045642 (OR = 0.18, 95%CI 0.04–0.76; p = 0.020) and greater value of body mass index (OR = 0.7 95%CI 0.51–0.94, p = 0.02) showed a protective effect.
Table 5

Backward logistic regression of factors involved in nevirapine induced liver toxicity

 

OR (95%CI)

p

aOR (95%CI)

p

Male vs Female

0.19 (0.04–0.94)

0.042

0.27 (0.06–1.30)

0.102

Age (× 1 year more)

0.96 (0.88–1.04)

0.293

 

MSM vs HE

0.24 (0.01–4.51)

0.338

 

IVDUs vs HE

2.20 (0.58–8.41)

0.247

 

Other vs HE

1.36 (0.06–29.16)

0.844

 

Caucasian vs Non-Caucasian

0.67 (0.08–5.64)

0.714

 

BMI (× 1 more)

0.70 (0.51–0.94)

0.020

0.72 (0.52–1.00)

0.050

Previous AIDS

0.67 (0.08–5.56)

0.713

 

Previous therapy duration (× 1 year more)

1.05 (0.90–1.23)

0.518

 

CD4 200–500 cell/μL vs < 200 cell/μL

1.17 (0.05–25.7)

0.920

1.51 (0.07–32.23)

0.790

CD4 > 500 cell/μL vs < 200 cell/μL

3.97 (0.21–74.51)

0.357

8.12 (0.42–156.90)

0.166

HIV-RNA (× 1 log10 more)

0.80 (0.54–1.18)

0.260

 

AST (× 1 more)

1.02 (1.01–1.03)

0.008

1.01 (0.99–1.03)

0.144

ALT (× 1 more)

1.01 (1.00–1.02)

0.015

 

HCV coinfection

6.93 (1.38–34.87)

0.019

8.00 (1.27–50.29)

0.027

HBV coinfection

2.39 (0.28–20.36)

0.427

 

ARV Backbone: AZT/DDI/D4T vs ABC

0.73 (0.12–4.47)

0.731

 

ARV Backbone: TDF vs ABC

0.12 (0.01–3.141)

0.204

 

ARV Backbone: Other vs ABC

0.49 (0.02–13.47)

0.672

 

ABCB1 rs1045642 CT/TT vs CC

0.18 (0.04–0.76)

0.020

0.10 (0.02–0.47)

0.004

Abbreviations: OR Odds Ratio, aOR adjusted Odds Ratio, CI confidence interval, HE Heterosexual, MSM Man how have sex with man, IVDUs Intra venous drug users, BMI Body Mass Index, cps copies, ABC abacavir, TDF tenofovir diproxil fumarate, BMI Body Mass Index, ABCB ATP Binding Cassette Subfamily B

In the multivariate logistic regression model (Table 5), HCV coinfection was confirmed to be independently associated with a higher risk of developing liver toxicity (aOR = 8.00, 95%CI 1.27–50.29; p = 0.027), whereas ABCB1 CT/TT genotypes (aOR = 0.10, 95%CI 0.02–0.47; p = 0.004) has been associated with a lower risk; a higher body mass index (aOR = 0.72, 95%CI 0.519–1.000; p = 0.050) has been barely related to a lower risk (Table 5). On the contrary, the association between gender, baseline AST levels and NVP-induced liver toxicity wasn’t confirmed in the final multivariate model.

Discussion

In this study conducted in a monocentric cohort of HIV-1 positive patients exposed to NVP we observed, during the first three months of treatment, an incidence of severe liver toxicity of 2.2%. This finding is similar to that reported by other cohorts when NVP was used in experienced patients [10, 22]. We did not observe a significant association between the development of hepatotoxicity and high CD4 cells count at NVP start, supporting the observation of low frequency of NVP induced liver toxicity in experienced patients [10]. The mechanisms involved in the development of severe hepatotoxicity are not well explained and it could be that in patients never exposed to antiretroviral therapy immune-mediated process leading to immune-reconstitution could elicit the development of liver toxicity [23]. On the contrary, in experienced patients with a stable immune-virological situation, hepatotoxicity could be driven by a direct effect of the drug in susceptible patients [24]. We confirm previous findings supporting the importance of HCV coinfection as independent factor associated to the development of NVP-related liver toxicity; HCV infection could play a direct role causing liver injury and also could interfere with the metabolism of the drug [8, 11, 25]. The enhanced risk of development hepatotoxicity in HCV coinfected patients treated with NVP seems to be independent from NVP plasmatic concentrations, since comparable NVP concentration are observed in patients with and without HCV coinfection [26].

A significant correlation between low value of body mass index (< 18.5) such as for increased NVP plasma concentration and increased risk for hepatotoxicity has been previously reported [12, 18], in our study we observed a trend of body weight in predisposing to NVP-hepatotoxicity albeit not confirmed in the multivariate model.

In accordance with previous studies, we did not found a statistically significant association between polymorphisms in CYPs genes (CYP2B6, CYP3A4, CYP3A5) and the development of severe hepatotoxicity. Although these genes are involved in NVP metabolism [27] and their functional variants may significantly affect NVP plasma concentrations [2830], their role in predisposing NVP induced hepatotoxicity remains unclear [19, 31].

The ABCB1 gene encodes for P-glycoprotein, one of the most important efflux pomp involved in the transport of both NVP and efavirenz and a modification of this protein could determine an alteration in the intracellular concentration of these drugs [32].

Interestingly, the functional variant c.3435 C > T of ABCB1 gene was associated with an increases risk for severe liver toxicity in a previous study conducted by Hass et al. in South-Africa [19]. Moreover, the variant ABCB1 c.3435 C > T resulted protective for NVP-associated hepatic adverse events in another study conducted in Mozambique [20]. No statistically significant association between ABCB1 c.3435 C > T and NVP adverse events was found in another study conducted by Yuan J et al. in an ethnic mixed population. However, these authors found a significant association between ABCB1 c.3435 C > T variant and hepatic adverse events among Africans but not Asians or Caucasians, despite these latter groups showed increased T-allele frequencies [31].

Overall our study, which was conducted on a prevalently European Caucasian population, disagrees with the study by Yan et al. On the contrary it supports the protective role of T allele of ABCB1 rs1045642 for NVP-hepatotoxicity evidenced by Hass et al. and Ciccacci et al.

The present study has some limitations. In particular, due to the retrospective design we cannot exclude the presence of possible bias related to loss of data. A sub-optimal performance of RUCAM, which is more fitted for a prospective patient evaluation, could be hypothesized because of the retrospective nature of the study. Moreover, if on one hand the limited number of NVP induced hepatic adverse events supports the good safety profile of this drug in ART-experienced patients, on the other hand our study could not exclude that the prevalence of the investigated polymorphisms could be driven by chance. Moreover, the prevalence of Caucasian ethnicity limited the comparison of our findings between different ethnic groups.

Conclusion

Beyond to clinical conditions well known to drive the development of hepatotoxicity during NVP treatment, i.e. HCV coinfection and body mass index, pharmacogenomic profiles could also play a role in this phenomenon. Our results suggest the independent role of ABCB1 rs1045642 as a predictive marker of severe liver toxicity related to NVP. Further validation studies, to assess possible clinical application of this marker in countries in which NVP is still widely used and/or in patients with other risk factors for nevirapine related toxicity, are warranted.

Abbreviations

ABCB: 

ATP Binding Cassette Subfamily B

aOR: 

Adjusted Odds Ratio

ART: 

Antiretroviral treatment

CI: 

Confidence interval

CYP: 

Cytochrome P450 enzyme

HIV-1: 

Human immunodeficiency virus type 1

IQR: 

Inter quartile range

NVP: 

Nevirapine

OR: 

Odds Ratio

RUCAM: 

Roussel Uclaf Causality Assessment Methods

SNPs: 

Single nucleotide polymorphisms

Declarations

Acknowledgements

We thank Mrs. Tiziana Formenti for the excellent technical help.

Funding

No financial support to this study.

Availability of data and materials

The data sets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Authors’ contributions

AG, ALR, AR, FSF, MLO, MG, SR designed the study. GR, VDC, AL assessed the patient’s documentation and evaluated the inclusion in the study. AG, ALR, GR, VDC, AL, were involved in data collection and interpretation. FSF, EC, DC, SC performed laboratory analyses. AG, MLO were responsible for the statistical analyses. All authors interpreted the data and drafted the manuscript. All authors have critically revised and approved the final version.

Ethics approval and consent to participate

The study was reviewed and approved by our ethics committee (Comitato Etico Interaziendale, Milano area 1); all subjects signed a dedicated informed consent.

Consent for publication

Not applicable.

Competing interests

S.R. has received consultancy payments and speaking fee from Bristol-Myers Squibb, Gilead, ViiV Healthcare, Merck Sharp Dohme, ABBvie and Janssen. M.G. has received consultancy payments and speaking fee from Bristol-Myers Squibb, Gilead, ViiV Healthcare, Merck Sharp Dohme, ABBvie, Janssen and Roche.

Preliminary data of this study were presented as poster presentation (PE10/15) at the 16th European AIDS conference, October 25–27, 2017 Milan, Italy.

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Infectious Diseases Unit, DIBIC Luigi Sacco - University of Milan, Via G.B. Grassi, 74, 20157 Milan, Italy
(2)
ASST Fatebenefratelli-Sacco, Clinical Pharmacology Unit, Milan, Italy
(3)
E. Medea Scientific Institute, Bosisio Parini, Italy

References

  1. Milinkovic A, Martínez E. Nevirapine in the treatment of HIV. Expert Rev Anti-Infect Ther. 2004;2:367–73.View ArticleGoogle Scholar
  2. De Boissieu P, Dramé M, Raffi F, et al. Dat’AIDS study group. Long-term efficacy and toxicity of abacavir/lamivudine/nevirapine compared to the most prescribed ARV regimens before 2013 in a French Nationwide cohort study. Medicine (Baltimore). 2016;95(37):e4890.View ArticleGoogle Scholar
  3. Reliquet V, Allavena C, Morineau-Le Houssine P, Mounoury O, Raffi F. Twelve-year experience of nevirapine use: benefits and convenience for long-term management in a French cohort of HIV-1-infected patients. HIV Clin Trials. 2010;11(2):110–7.View ArticleGoogle Scholar
  4. Llibre JM, Bravo I, Ornelas A, et al. Effectiveness of a treatment switch to Nevirapine plus Tenofovir and Emtricitabine (or lamivudine) in adults with HIV-1 suppressed viremia. PLoS One. 2015;10(6):e0128131.View ArticleGoogle Scholar
  5. Patel SM, Johnson S, Belknap SM, et al. Serious adverse cutaneous and hepatic toxicities associated with nevirapine use by non-HIV-infected individuals. J Acquir Immune Defic Syndr. 2004 Feb 1;35(2):120–5.View ArticleGoogle Scholar
  6. Stern JO, Robinson PA, Love J, et al. A comprehensive hepatic safety analysis of nevirapine in different populations of HIV infected patients. J Acquir Immune Defic Syndr. 2003;34(Suppl. 1):S21–33.View ArticleGoogle Scholar
  7. Dieterich DT, Robinson PA, Love J, Stern JO. Drug-induced liver injury associated with the use of nonnucleoside reverse-transcriptase inhibitors. Clin Infect Dis. 2004;38(Suppl. 2):S80–9.View ArticleGoogle Scholar
  8. Wu PY, Cheng CY, Liu CE, et al. Multicenter study of skin rashes and hepatotoxicity in antiretroviral-naïve HIV-positive patients receiving non-nucleoside reverse-transcriptase inhibitor plus nucleoside reverse-transcriptase inhibitors in Taiwan. PLoS One. 2017 Feb 21;12(2):e0171596.View ArticleGoogle Scholar
  9. Kesselring AM, Wit FW, Sabin CA, Lundgren JD, Gill MJ, Gatell JM, et al. Risk factors for treatment-limiting toxicities in patients starting nevirapine-containing antiretroviral therapy. AIDS. 2009;23:1689–99.View ArticleGoogle Scholar
  10. Mocroft A, Staszewski S, Weber R, et al. EuroSIDA study group. Risk of discontinuation of nevirapine due to toxicities in antiretroviral-naïve and -experienced HIV-infected patients with high and low CD4+ T-cell counts. Antivir Ther. 2007;12(3):325–33.PubMedGoogle Scholar
  11. Van Welzen B, Mudrikova T, Arends J, Hoepelman A. No increased risk of hepatotoxicity in long-term use of nonnucleoside reverse transcriptase inhibitors in HIV-infected patients. HIV Med. 2012;13(7):448–52.View ArticleGoogle Scholar
  12. Sanne I, Mommeja-Marin H, Hinkle J, et al. Severe hepatotoxicity associated with nevirapine use in HIV-infected subjects. J Infect Dis. 2005;191(6):825–9.View ArticleGoogle Scholar
  13. Riska P, Lamson M, MacGregor T, Sabo J, Hattox S, Pav J, Keirns J. Disposition and biotransformation of the antiretroviral drug nevirapine in humans. Drug Metab Dispos. 1999;27:895–901.PubMedGoogle Scholar
  14. Bertrand J, Chou M, Richardson DM, et al. ANRS 12154 study group. Multiple genetic variants predict steady-state nevirapine clearance in HIV-infected Cambodians. Pharmacogenet Genomics. 2012;22(12):868–76.View ArticleGoogle Scholar
  15. Penzak SR, Kabuye G, Mugyenyi P, et al. Cytochrome P450 2B6 (CYP2B6) G516T influences nevirapine plasma concentrations in HIV-infected patients in Uganda. HIV Med. 2007;8(2):86–91.View ArticleGoogle Scholar
  16. Wyen C, Hendra H, Vogel M, et al. Impact of CYP2B6 983T>C polymorphism on non-nucleoside reverse transcriptase inhibitor plasma concentrations in HIV-infected patients. J Antimicrob Chemother. 2008;61:914–8.View ArticleGoogle Scholar
  17. Rotger M, Colombo S, Furrer H, et al. Influence of CYP2B6 polymorphism on plasma and intracellular concentrations and toxicity of efavirenz and nevirapine in HIV-infected patients. Pharmacogenet Genomics. 2005;15:1–5.View ArticleGoogle Scholar
  18. Gozalo C, Grard L, Loiseau P, et al. For the ANRS 081 study group pharmacogenetics of toxicity, plasma trough concentration and treatment outcome with Nevirapine-containing regimen in anti-retroviral-nave HIV-infected adults: an exploratory study of the TRIANON ANRS 081 trial. Basic & Clinical Pharmacology & Toxicology. 2011;109:513–20.View ArticleGoogle Scholar
  19. Haas DW, Bartlett JA, Andersen JW, et al. Pharmacogenetics of nevirapine-associated hepatotoxicity: an adult AIDS Clinical Trials Group collaboration. Clin Infect Dis. 2006;43:783–6.View ArticleGoogle Scholar
  20. Ciccacci C, Borgiani P, Ceffa S, et al. Nevirapine-induced hepatotoxicity and pharmacogenetics: a retrospective study in a population from Mozambique. Pharmacogenomics. 2010;11:23–31.View ArticleGoogle Scholar
  21. Danan G, Teschke R. RUCAM in drug and herb induced liver injury: the update. Int J Mol Sci. 2016;17(1):14.View ArticleGoogle Scholar
  22. Brück S, Witte S, Brust J, et al. Hepatotoxicity in patients prescribed efavirenz or nevirapine. Eur J Med Res. 2008;13:343–8.PubMedGoogle Scholar
  23. Bekker Z, Walubo A, du Plessis JB. The role of the immune system in Nevirapine-induced subclinical liver injury of a rat model. ISRN Pharmaceutics. 2012;2012:932542.View ArticleGoogle Scholar
  24. Núñez M. Hepatotoxicity of antiretrovirals: incidence, mechanisms and management. J Hepatol. 2006;44(1 Suppl):S132–9 Epub 2005 Nov 28.View ArticleGoogle Scholar
  25. Sulkowski MS, Thomas DL, Chaisson RE, Moore RD. Hepatotoxicity associated with antiretroviral therapy in adults infected with human immunodeficiency virus and the role of hepatitis C or B virus infection. JAMA. 2000;283:74–80.View ArticleGoogle Scholar
  26. Vogel M, Bertram N, Wasmuth JC, Wyen C, Voigt E, Schwarze-Zander C, Sudhop T, Fätkenheuer G, Rockstroh JK, Reichel C. Nevirapine pharmacokinetics in HIV-infected and HIV/HCV-coinfected individuals. J Antimicrob Chemother. 2009 May;63(5):988–91.View ArticleGoogle Scholar
  27. Wen B, Chen Y, Fitch WL. Metabolic activation of nevirapine in human liver microsomes: dehydrogenation and inactivation of cytochrome P450 3A4. Drug Metab Dispos. 2009 Jul;37(7):1557–62.View ArticleGoogle Scholar
  28. Schipani A, Wyen C, Mahungu T, et al. German competence network for HIV/AIDS. Integration of population pharmacokinetics and pharmacogenetics: an aid to optimal nevirapine dose selection in HIV-infected individuals. J Antimicrob Chemother. 2011;66(6):1332–9.View ArticleGoogle Scholar
  29. Mahungu T, Smith C, Turner F, et al. Cytochrome P450 2B6 516G-->T is associated with plasma concentrations of nevirapine at both 200 mg twice daily and 400 mg once daily in an ethnically diverse population. HIV Med. 2009 May;10(5):310–7.View ArticleGoogle Scholar
  30. Giacomelli A, Rusconi S, Falvella FS, et al. Clinical and genetic determinants of nevirapine plasma trough concentration. SAGE Open Med. 2018;6:2050312118780861.View ArticleGoogle Scholar
  31. Yuan J, Guo S, Hall D, et al. Nevirapine Toxicogenomics study team. Toxicogenomics of nevirapine-associated cutaneous and hepatic adverse events among populations of African, Asian, and European descent. AIDS. 2011;25(10):1271–80.View ArticleGoogle Scholar
  32. Owen A, Pirmohamed M, Khoo HS, Back DJ. Pharmacogenetics of HIV therapy. Pharmacogenet Genomics. 2006;16:693–703.View ArticleGoogle Scholar
  33. Zanger UM, Schwab M. Cytochrome P450 enzymes in drug metabolism: regulation of gene expression, enzyme activities, and impact of genetic variation. Pharmacol Ther. 2013 Apr;138(1):103–41.View ArticleGoogle Scholar
  34. Kitzmiller JP, Sullivan DM, Phelps MA, Wang D, Sadee W. CYP3A4/5 combined genotype analysis for predicting statin dose requirement for optimal lipid control. Drug Metabol Drug Interact. 2013;28(1):59–63.View ArticleGoogle Scholar

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© The Author(s). 2018

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