What is the role of non-nucleoside reverse transcriptase inhibitors in the management of pregnant women with HIV infection?

Updated: Apr 02, 2019
  • Author: Ashley T Peterson, MD; Chief Editor: Ronald M Ramus, MD  more...
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Five NNRTIs are FDA approved: delavirdine (Rescriptor), efavirenz (Sustiva), etravirine (Intelence), nevirapine (Viramune), and rilpivirine (Edurant). Although less information is available regarding NNRTI use in pregnancy, nevirapine and efavirenz both cross the placenta. The most common side effect is rash, which can occur in up to 17% of patients on nevirapine.

Use of efavirenz was previously not recommended in the first trimester because of reported cases of fetal neural tube defects, however, based on additional data the NIH now classifies this drug as an acceptable alternative agent.

Severe nevirapine-associated skin rash and hepatic toxicity have been reported in pregnancy. The potentially fatal hepatotoxicity appears to be increased in women, during pregnancy, and in patients with a CD4+ T-cell count greater than 250 cells/mL. Because of these significant complications, nevirapine should not be used as first-line therapy unless no other option is available.

In women whose CD4+ T-cell counts were below 200 cells/mL and who were previously exposed to peripartum single-dose nevirapine, ritonavir-boosted lopinavir plus tenofovir-emtricitabine was superior to nevirapine plus tenofovir-emtricitabine for initial antiretroviral therapy. [29]

In children previously exposed to single-dose nevirapine for perinatal prevention of HIV transmission, zidovudine and lamivudine plus ritonavir-boosted lopinavir for antiretroviral treatment resulted in better outcomes than treatment with zidovudine and lamivudine plus nevirapine. [30]

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