12 - Adverse psychiatric effects of antiretroviral

Adverse psychiatric effects of antiretroviral drugs

808 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 10 Table 10.2  Summary of psychiatric adverse drug reactions (ADRs) with antiretroviral drugs.21,40–45 Drug Adverse psychiatric effects/comments Nucleoside reverse transcriptase inhibitors Abacavir Depression, anxiety, nightmares, labile mood, mania, psychosis. Very few cases reported. In all reported cases, the patient rapidly returned to baseline after discontinuing drug. Didanosine Lethargy, nervousness, anxiety, confusion, sleep disturbance, mood disorders, psychosis, mania. Very rare. Emtricitabine Confusion, irritability, insomnia Tenofovir alafenamide Insomnia Zidovudine Sleep disturbance, vivid dreams, agitation, mania, depression, psychosis, delirium. Psychiatric ADRs are usually dose-­related. Onset varies widely, from <24 hours to 7 months. Non-­nucleoside reverse transcriptase inhibitors Efavirenz Somnolence, insomnia, abnormal dreams, impaired concentration, depression, psychosis, suicidal ideation. Symptoms usually subside or diminish after 2–4 weeks. However, subtler long-­term neuropsychiatric effects may occur. Can exacerbate psychiatric symptoms; avoid in patients with a history of psychiatric illness. Adverse psychiatric effects of antiretroviral drugs Psychiatric adverse events have been reported with most antiretroviral drugs, but a causal relationship remains uncertain for many. Efavirenz has been most commonly implicated, and HIV guidelines suggest avoiding its use in patients with psychiatric comorbidity. Table 10.2 summarises the most important psychiatric adverse effects of antiretroviral drugs. Note that this is not an exhaustive list and readers are directed to the summaries of product characteristics/product labelling for greater detail. Potential adverse effect Implicated antiretroviral drug(s)21,42,43 Implications for psychotropic prescribing Seizure(s) Darunavir, efavirenz, maraviroc, ritonavir, saquinavir, zidovudine May increase seizure risk associated with certain psychotropic drugs (e.g. clozapine) Metabolic abnormalities such as hypertriglyceridaemia, hypercholesterolaemia, insulin resistance, hyperglycaemia and hyperlactataemia All combination antiretroviral therapy Raltegravir, elvitegravir, dolutegravir: greater risk of weight gain May compound risk of metabolic adverse effects associated with certain psychotropic drugs (particularly SGAs) INSTIs, integrase strand transfer inhibitors; NMS, neuroleptic malignant syndrome; NNRTIs, non-­nucleoside reverse transcriptase inhibitors; PIs, protease inhibitors. Table 10.1  (Continued )