CASE 2• 54 yo man…HIV+ 1997• PCP• Cryptospordiasis• Chronic HepC • Genotype 1a• Biopsy… 2/4 activity, 3/4scarring

• CD4 40 • No baseline genotype

CASE 21998-2002D4T/3TC/Indinavir initiated

• CD4 30 → 400• Viral load undetectable

CASE 2• U/A - ++ WBC + IDV crystals• Creatinine – 80 → 115

• Indinavir crystal induced interstitial renal disease felt to be responsible

CASE 22002-2008 • D4T/3TC/Nelfinavir

• Mild intermittent diarrhea• Successfully treated for Hepatitis C

with 48 wks of Peg Interferon/RBV• CD4 450-700 VL <50

CASE 22008 • D4T/3TC/Nelfinavir

• Ongoing diarrhea• Increasing recognition of

dorsocervical fat pad• Switched to TDF/FTC/Efavirenz

CASE 2TIME AST ALT OTHER10/08 33 31 Etoh 6 beers/day x yrs11/08 55 86 No increase in Etoh; HepA

IgG (+); HepBsAb (+)12/08 41 59 Workup for secondary liver

disease (-); HCV RNA (-); U/S… fatty liver

04/09 69 143 Repeat HCV RNA (-); Urinary Drug Screen (UDS) (-);

06/09 97 156 UDS (-)

WHAT WOULD YOU DO?

CASE 2June 2009

• TDF/FTC/Efavirenz switched to TDF/FTC/Etravirine to attempt to r/o Efavirenz as cause of hepatitis

CASE 2

TIME AST

ALT OTHER

07/09

64 140 1 month post-switch

08/09

58 117 2 months post switchWHAT WOULD YOU DO?

CASE 2

• TDF/FTC/Etravirine switched to D4T/3TC/Etravirine to attempt to r/o TDF/FTC as rare cause of hepatitis

CASE 2Sept/09 D4T/3TC/Etravirine

TIME AST ALT OTHER08/09 58 117 TDF/FTC/ETV09/09 47 6810/09 49 5511/09 54 91

WHAT WOULD YOU DO?

CASE 2• Switched back to TDF/FTC/Etravirine

as patient concerned about lipodystrophy and unclear whether liver improving at all from Etravirine or TDF/FTC switch

CASE 2TIME AS

TALT OTHER

11/09

54 122 D4T/3TC/Etravirine

03/10

64 143 TDF/FTC/Etravirine… No increase in Etoh

06/10

77 224WHAT IS HAPPENING?WHAT WOULD YOU DO?

CASE 2• Patient self-discontinues meds

TIME AST ALT06/10 77 22407/10 47 69

CASE 2• Restarted TDF/FTC/Efavirenz for

simplicity/convenienceTIME AST ALT OTHER07/10 47 69 No Meds07/10 97 145 2 wks08/10 97 193 4 wks09/10 68 189 8 wks

NOW WHAT?

CASE 2Late September 2010• Switched to D4T/3TC/Raltegravir as

previously had normal liver enzymes for years on D4T/3TC/Nelfinavir and need to get rid of TDF/FTC and NNRTI class.

• Refused PI due to lipohypertrophySTAY TUNED!!!