HIV and ID Observations

An ongoing dialogue on HIV/AIDS, infectious diseases,
all matters medical, and some not so medical.

March 1st, 2009

Sedation for Colonoscopies in HIV Patients: Debate Rages

Here’s a problem we’re grappling with:

A patient with HIV needs a colonoscopy, but is on either a ritonavir-boosted protease inhibitor or an efavirenz-based regimen.

(This must be something like 90% of HIV patients as of March 1, 2009, based on my extremely unscientific gut impression.)

For efavirenz, midazolam is contraindicated; for ritonavir, same story — or “consider therapy modification”, according to one source I found.  Ditto fentanyl.

So what should be given for sedation?  (Important side note: if you told me pre-1996 that this would be a critical management question for my HIV patients, I would have thought you were out of your mind.)

Lots of different views here in Boston, including:

  • Give the usual meds, titrate to effect
  • NEVER give midazolam with either efavirenz or ritonavir; instead, use lorazepam, etc
  • Stop HIV meds 1 day in advance, then give midazolam and fentanyl

Does anyone know?  Or does anyone have sufficient experience to share?

Categories: Antiretroviral Rounds, HIV, Patient Care
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4 Responses to “Sedation for Colonoscopies in HIV Patients: Debate Rages”

  1. Bob Arnold says:
    March 1, 2009 at 9:21 pm

    I would titrate to effect. After all, we use fentanyl patches in patients on efavirenz. You just start at a lower dose.

  2. Brian Fennerty says:
    March 9, 2009 at 1:18 pm

    Paul, I would sedate as usual as it has been my experience (hundreds of cases of endoscopy in patients on these meds) that there are no significant adverse effects, and there are no cases of clinically relevant drug interactions using fentanyl/midazolam for conscious sedation in patients on these agents (thousands of cases). Until it is a clinical relevant interaction (vs pharmacological or theoretical effect as it is at this time), deviating from a safe and time-tested sedation strategy for endoscopy does not seem justified.

  3. Paul Sax says:
    March 9, 2009 at 9:35 pm

    Brian, many thanks for your input — will share with our colleagues.

    Paul

  4. Sedating HIV-Infected Endoscopy Patients | Gut Check says:
    March 14, 2009 at 8:13 pm

    […] HIV-Infected Endoscopy Patients Posted by M. Brian Fennerty on March 14th, 2009 In a recent blog post, ID expert Paul Sax raised the question of which sedatives should be used when scoping HIV-infected […]

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Associate Editor

NEJM Clinician

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