Child protection issues around starting efavirenz in a mother on maintenance methadone

Abstract

Initiation of efavirenz often results in neurological symptoms such as nightmares or agitation in the first 5 days (Clarke SM, et al. Efavirenz therapy in drug users. HIV Medicine 2000). For patients on maintenance methadone reduced blood levels from 7 – 10 days onwards may lead to withdrawal symptoms. We wish to report one patient where significant child protection issues arose within 72 h of starting efavirenz.

A 40 year old white female who was on maintenance methadone 45 mg daily was admitted to be with her 3 year old while she was observed during starting a HAART regime including efavirenz 600 mg at night. The day after the third dose she interacted in a very agitated way with her child and staff had to separate them. Further threatening behaviour followed, including shaking the child violently. She also had vivid nightmares while taking efavirenz, and declined to take prescribed phenothiazines.

She went out each day to use street heroin to control her symptoms. Efavirenz was stopped after 7 days. After 3 days she began nevirapine. She later developed mild opiate withdrawal symptoms with aching and sweating, but no agitation or further threat to the child. Had this patient started efavirenz at home unsupervised, her child could have been injured. This appeared to be due to the neurological effects of efavirenz rather than opiate withdrawal. There had been no sign of physical or emotional neglect or violence at any of the 12 previous admissions to this clinic and the child had always been well fed, clean and clothed and cared for. Caution should be exercised on starting efavirenz in mothers who care for small children.

Comment

Severe neuropsychiatric symptoms have previously been described in association with efavirenz. This study clearly differentiated the difference between symptoms related to efavirenz and methadone withdrawal which only occur after day 7-10 of treatment.

Although studies have failed to identify those patients at higher risk, a history of psychiatric illness would appear to be an indication to chose an alternative regimen when available.

Advising all new patients to the potential for these side effects and providing a clinic contact number should problems arise together with awareness of the option to switch to nevirapine should they persist is strongly recommended.

J. Meadway – Child protection issues around starting efavirenz in a mother on maintenance methadone. 5th Intl Congress on Drug Therapy in HIV Infection, Glasgow. 22-26 October 2000. Poster 178.