Renin-angiotensin system inhibition in a patient having an overdose of HIV protease inhibitor

Primary Aldosteronism with HIV Infection: Important Considerations When Using the Aldosterone:Renin Ratio to Screen This Unique Population

Primary aldosteronism (PA) was initially thought to be a rare cause of hypertension. Currently, the screening modality for PA in patients with presumed secondary hypertension is the aldosterone:renin ratio (ARR). Since the advent of the ARR, the prevalence rates of PA have increased dramatically in the general population. Recently however, several reviews have suggested flaws in the ARR, leading to a possible overestimation of the prevalence of this disease. Within the HIV-positive population, there are few documented cases of PA however. With the increasing reliance on the ARR to screen and diagnose this disorder, this number is likely to rise. It is now known that the HIV has rennin-like properties. Therefore, HIV infection itself can inappropriately alter the ARR. Additionally, the medication used to treat HIV infection can also affect this value. Although the ARR is a convenient tool for screening patients with possible PA, there are multiple associated concerns particularly when it is applied to the HIV-positive population. Therefore, further testing is essential in all HIV-positive patients in whom PA is suspected.

A five-year evaluation of reports of overdose with indinavir sulfate

PURPOSE

To describe the adverse event profile for indinavir sulfate overdose.

METHODS

Analysis of indinavir overdose reports in Merck & Co., Inc.'s safety database through the first 5 years following US licensure of indinavir. Reports were classified as acute (single high dose in excess of 2400 mg), chronic (multiple extra doses, not exceeding 2400 mg per dose), single extra dose (not exceeding 2400 mg) and dose not reported.

RESULTS

Seventy-nine reports of indinavir overdose were reviewed (15 acute, 43 chronic, 13 single extra dose and 8 dose not reported). A total of 52/79 (66%) reports were associated with adverse events. For acute overdose reports with adverse events, indinavir doses ranged from 2.8 g to 48 g (median 6 g; mean 13 g); for acute overdose reports without adverse events, indinavir doses ranged from 4 g to 80 g (median 56 g; mean 45 g). Adverse events following acute and chronic exposures were similar; the most commonly reported adverse events included nausea, vomiting, abdominal pain and nephrolithiasis. Of the 52 patients with adverse events, 39 recovered, 6 had not recovered at the time of reporting and no information regarding outcome was provided in 7 reports.

CONCLUSIONS

Overdose with indinavir was associated with adverse events in the majority of reports. These were most commonly gastrointestinal and renal events, and were generally consistent with the known safety profile of indinavir. The majority of patients recovered.