Both here and on the AIDS Clinical Care site, we posted a case of a 50-year-old HIV+ man in need of a screening colonoscopy. What sedation could he receive while on tenofovir/FTC and ritonavir-boosted atazanavir? Specifically, would midazolam and fentanyl (“contraindicated” in the ritonavir package insert) be ok?
(Same issue for efavirenz, by the way.)
We solicited responses from two PharmD’s and a gastroenterologist, and also received a bunch of comments.
The comments vary in specifics, but the most common is similar to this one, echoing what Brian Fennerty wrote:
These sedative drugs are always titrated to effect for individual patients. We are aware that responses are variable and I think it completely unnecessary to alter an HIV patient’s drug regimen to allow them to receive the discussed drugs. In my experience, I have never noticed a marked exaggeration in clinical effects in this scenario anyway. Bolus doses should be reduced and given with more caution, in the same manner that we approach any patient with altered metabolism, such as the elderly, or those known to have hepato-renal failure.
Or said another way, by a clinician receiving ART himself:
As someone who happens to be on efavirenz I received midazolam and fentanyl for a colonoscopy without incident at age 57 two years ago. The dosage used of both medications was comparable with that I have given patients many times for short relatively pain-free procedures before I retired from the practice of anesthesiology Dr. Fennerty’s approach is the one my gastroenterologist used and is one that I endorse. Giving sedation is all about titration according to individual response and circumstances. The additional caveat I have to make is that since the patient could have a prolonged response is to make sure that the recovery personnel are aware of that fact and are prepared to keep the patient under observation for as long as necessary. This might mean scheduling the case earlier in the day so there is no time pressure to discharge the patient.
We may never have complete consensus on this issue, but ultimately this makes the most sense — use the usual drugs, but be aware that there might be a clinically-relevant interaction in some patients.
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