Love Your Liver?

The U.S. National Library of Medicine flags efavirenz, an antiretroviral drug typically used in combination with other ARTs, as having an “uncommon but well established cause of clinically apparent acute liver injury.”

Switching from efavirenz to raltegravir as a replacement significantly decreases chances of developing fatty liver disease, suggests a Spanish study in Oxford’s Clinical Infectious Diseases, which observed HIV-positive people — as well as those who are both poz and living with hepatitis C. Of 39 people with suppressed viral loads and hepatic steatosis (fatty liver disease), 19 were switched to raltegravir, and the other 20 continued to take efavirenz. After 48 weeks, those who switched meds showed fewer hepatic steatosis symptoms.

“HIV-infected individuals switching efavirenz to raltegravir showed decreases in the degree of hepatic steatosis... compared with those continuing with efavirenz,” researchers concluded. “In addition, the proportion of patients without significant hepatic steatosis after 48 weeks was greater for those who switched.” The participants’s livers were assessed using a Fibroscan, which measures liver stiffness and the accumulation of fat.

It takes one to eight weeks for symptoms of liver hepatotoxicity to appear, which often includes a rash or a fever. A separate study points to doravine as another alternative to efavirenz, showing that people taking doravine experienced fewer neuropsychiatric events.

In addition to liver and cholesterol problems, the evidence has shown that efavirenz can cause profound hallucinations, mood swings, suicidal thoughts and, as one study published in the journal Neuropsychopharmacology found, “LSD-like properties.” Despite those dangers, the drug is quite popular worldwide. Switching to raltegravir reduces the risks, though you will pay a pretty penny for the less-toxic qualities. The monthly cost of efavirenz is $1,010 compared to $1,713 a month for raltegravir.

In the United States, efavirenz is often sold individually as Sustiva, raltegravir as Isentress. No doubt, raltegravir will surely grow in popularity as a less toxic alternative. Efavirenz is also used as one of the three drugs in the tablet Atripla, a common once-a-day HIV regimen­ — becoming one of the best-known drugs to pass the blood-brain barrier.

Mylan Pharmaceuticals got the green light to launch a generic version of Atripla containing efavirenz in Canada. Avonza, a very similar generic drug containing efavirenz, was launched in India in August. Avonza is lower than half the price of first-line antiretrovirals. The Indian company produces 4 billion antiretroviral tablets per year. In Costa Rica, efavirenz was so popular that authorities announced an inventory crisis in August. Because of its psychotropic properties, it is reportedly (and foolishly) being used recreationally in South Africa, where HIV drugs can be found relatively easy on the black market.

Modern drugs are an improvement from older generation drugs like AZT, but HIV-positive people have enough to worry about without having to be concerned with hallucinations, suicidal thoughts, or the inability to think clearly. There are safer alternative drug regimens out there.

Stribild and Genvoya, for instance, are efavirenz-free and potentially less risky drug regimens compared to Atripla, and chances are your out-of-pocket premium will stay the same. Doctors will rarely inform you on their own about the latest drugs that are available, so be sure to ask yours about treatment alternatives.