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The Interaction of CD4 T-Cell Count and Nevirapine Hepatotoxicity in China: A Change in National Treatment Guidelines May Be Warranted

Zhang, Chengda*; Wang, Wei MD*; Zhou, Mengyu*; Han, Yang MD*; Xie, Jing MD, PhD*; Qiu, Zhifeng MD, PhD*; Guo, Fuping MD, PhD*; Li, Yanling MD*; Wang, Huanling MD, PhD*; Ghanem, Khalil G. MD; Li, Taisheng MD, PhD*

JAIDS Journal of Acquired Immune Deficiency Syndromes: 15 April 2013 - Volume 62 - Issue 5 - p 540–545
doi: 10.1097/QAI.0b013e3182845cc7
Clinical Science

Objectives: Nevirapine (NVP), a still widely used nonnucleoside reverse transcriptase inhibitor, can cause severe hepatotoxicity. Previous studies suggest that CD4 cell counts more than 250 cells per microliter in women and more than 400 cells per microliter in men are risk factors for NVP-related hepatotoxicity. These studies have informed Chinese national treatment guidelines. We evaluate whether current Chinese guidelines for NVP use are appropriate.

Methods: Longitudinal data were pooled from 2 clinical trials between 2005 and 2009 across mainland China. Five hundred sixty-six antiretroviral therapy–naive Chinese patients were given NVP-containing antiretroviral therapy for 24 weeks. Hepatotoxicity was defined as alanine aminotransferase, aspartate transaminase, or total bilirubin level greater than 1.25 times the upper limit of normal range. Severe hepatotoxicity was defined as greater than 5 times the upper limit of normal range.

Results: One hundred ninety-seven (36.1%) patients developed hepatotoxicity during treatment, including 42 (7.7%) patients with severe hepatotoxicity. CD4 cell count more than 250 cells per microliter was an independent predictor for hepatotoxicity both in men [relative risk = 1.22 (95% confidence interval: 1.04 to 1.44)] and in women [relative risk = 1.72 (95% confidence interval: 1.20 to 2.46)]. Severe hepatotoxicity was also more common among all persons with CD4 >250 cells per microliter.

Conclusions: Hepatotoxicity was a common adverse effect of NVP among men and women with CD4 >250 cells per microliter. Chinese treatment guidelines should be considered to reflect this risk.

*Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, P. R. China; and

Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD.

Correspondence to: Taisheng Li, MD, PhD, Department of Infectious Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan, Wangfujing Street, Beijing, China 100730 (e-mail: litsh@263.net).

Supported by the National Natural Science Foundation of China (grant 81071372 to T.L.); National Key Technologies R&D Program for the 12th Five-Year Plan (grant 2012ZX10001003-001); and Key Clinical Program of the Ministry of Health (2010–2012). J.X. was supported by the grant of Chinese Ministry of Human Resources and Social Security (2011).H.W. was supported by National Key Technologies R&D Program for the 12th Five-Year Plan (Grant 2012ZX09303013).

The authors T.L. designed the study. T.L., H.W., and K.G.G. provided critical review of this article. Y.H., J.X., Z.Q., F.G., Y.L., and H.W. preserved the sample and collected the data. W.W. and Y.H. did the laboratory test. C.Z., W.W., and M.Z. analyzed the data. C.Z., W.W., and M.Z. wrote the article.

The authors have no conflicts of interest to disclose.

Received October 11, 2012

Accepted December 20, 2012

© 2013 Lippincott Williams & Wilkins, Inc.