HIV-Protease Inhibitors

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Abstract
In his review of inhibitors of human immunodeficiency virus (HIV)–encoded protease (April 30 issue),1 Dr. Flexner states that ritonavir causes hypertriglyceridemia in no more than 5 percent of patients and has not caused pancreatitis. However, we found that of 52 patients treated with ritonavir for six months, 41 (79 percent) had hypertriglyceridemia (serum triglyceride concentration, >160 mg per deciliter [1.8 mmol per liter]), with values higher than 500 mg per deciliter (5.6 mmol per liter) in 22 patients (42 percent) and higher than 1000 mg per deciliter (11.3 mmol per liter) in 8 (15 percent). The risk varied as a function of the base-line serum triglyceride concentration. Among the 24 patients who had normal base-line concentrations, 5 (21 percent) had concentrations higher than 500 mg per deciliter (in at least one determination at month 1, 3, or 6), whereas 17 of the 28 patients (61 percent) with high concentrations before treatment had further increases during treatment. The risk of a serum triglyceride concentration higher than 1000 mg per deciliter during treatment was 4 percent in the group with normal base-line values and 25 percent in the group with elevated base-line values. Acute pancreatitis developed in two patients in the latter group (serum triglyceride concentrations, 1980 and 1880 mg per deciliter [22.4 and 21.2 mmol per liter]); it resolved with conventional medical management and the withdrawal of ritonavir. In both patients, the serum triglyceride concentration was less than 500 mg per deciliter within 10 days after the withdrawal of ritonavir.

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