From the Guidelines
The best next step in management for this 38-year-old pregnant woman with HIV on antiretroviral therapy who has significantly elevated liver enzymes (AST 300 U/L and ALT 254 U/L) is to evaluate her antiretroviral medication regimen and consider changing it, as this patient is likely experiencing antiretroviral-induced hepatotoxicity, a known side effect of many HIV medications 1. The markedly elevated transaminases with normal alkaline phosphstex, absence of biliary obstruction on ultrasound, and otherwise normal clinical presentation point to medication-induced liver injury rather than viral hepatitis, preeclampsia, or other pregnancy complications.
Key considerations in managing this patient include:
- The patient's HIV viral load is undetectable, indicating effective antiretroviral therapy, but the elevated liver enzymes suggest hepatotoxicity, which is a significant concern 1.
- Common offending agents include nevirapine, efavirenz, and certain protease inhibitors, which are known to cause hepatotoxicity 1.
- Liver function tests should be monitored closely after medication adjustment, typically every 1-2 weeks initially.
- It's essential to maintain HIV viral suppression throughout pregnancy to prevent maternal disease progression and vertical transmission to the fetus, so antiretroviral therapy should not be completely discontinued 1.
Given the potential risks and benefits, consultation with an HIV specialist is advisable to select the most appropriate alternative regimen that balances maternal liver health with effective HIV management during pregnancy. This approach will help minimize the risk of hepatotoxicity while maintaining viral suppression and preventing maternal and fetal complications 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Management
The patient is a 38-year-old woman, gravida 2 para 1, at 28 weeks gestation with a history of HIV and antiretroviral therapy. Her laboratory results show elevated liver enzymes, including aspartate aminotransferase (SGOT) and alanine aminotransferase (SGPT). The best next step in management would be to:
- Investigate the cause of elevated liver enzymes, considering her history of HIV and antiretroviral therapy 2, 3, 4
- Monitor her liver function closely, as liver disease is a major cause of morbidity and mortality in HIV-infected persons 2, 3, 4
- Consider the potential effects of antiretroviral therapy on liver disease, including the possibility of immune reconstitution disease 5, 6
Considerations for Antiretroviral Therapy
The patient has been on antiretroviral therapy since being diagnosed with HIV 3 years ago, and her last viral load was undetectable. Considerations for her antiretroviral therapy include:
- The potential benefits of antiretroviral therapy in reducing the progression of liver fibrosis and downregulating liver inflammation 6
- The potential risks of antiretroviral therapy, including drug-related liver injury 6
- The importance of monitoring her liver function closely while on antiretroviral therapy 2, 3, 4
Next Steps
The next steps in management would be to:
- Order further laboratory tests to investigate the cause of elevated liver enzymes, such as hepatitis panel and autoimmune liver disease tests
- Monitor her liver function closely, including regular liver enzyme tests and ultrasound examinations
- Consider consulting a hepatologist or an infectious disease specialist to guide management of her liver disease and antiretroviral therapy 2, 3, 4, 5, 6