Question

What can I do about my high levels of bilirubin now I am on atazanavir?

27 April 2011. Related: All topics, Changing treatment, Side effects.

Hi,
I am on a combination of atazanavir, Truvada and Norvir (ritonavir). Although I am happy with my current regimen, the only problem I have is hyperbilirubina. My bilirubin levels are, and have been over 6 times the maximum normal limit. My other liver function parameters are OK.

The only physically manifest symptom is the severe yellowing of my eyes. I have tried things like keeping hydrated but that does not seem to help.

Much as annoying as it is (yellowing) of eyes, I want to be on my current regimen. My only concern is are there any long term consequences of very high bilirubin on general health and health of the liver in particular.

Having HIV is a long haul and the kidneys, liver are the two principal organs where drugs are metabolises. I am concerned that this high level of bilirubin will cause irreversible damge to liver and other vital organs.

Do you think having this level of bilirubin is dangerous in the long term?

Answer

Answer: Charlotte Walker

Thank you for your question.

I am sorry to hear you are having so many problems with your bilirubin levels. If your bilirubin levels are more than 5 times the normal level then this could be damaging your liver so you need to be careful and find a way of getting the levels down as soon as possible.

If you are getting on ok with atazanavir there are some things you can try without having to switch medication if you would prefer?

One of the problems with protease inhibitors such as atazanavir, which are boosted with ritonavir is that the levels of drug in the body can vary depending on the individual. Ritonavir boosts atazanavir levels to around 10 times higher and makes them more consistent.

It is possible that the atazanavir levels are getting too high in your body. You need to ask your doctor about a Therapeutic Drug Monitoring (TDM) test. This is a test which measures the level of drugs in your blood. For more informaiton on TDM please follow this link.

If your drug levels are too high you may find that the doctor either reduces the amount of atazanavir and ritonavir you take or stops the ritonavir and slightly increases the atazanavir (e.g. from 300 to 400mg per day). It is fine to change the levels of these drugs if your viral load is undetectable. If you still have a detectable viral load your doctor may be less keen to try different dosages of atazanavir.

If you are taking Truvada which contains tenofovir and FTC, then you will need to change this if you stop the ritonavir. This is because tenofovir reduces the levels of atazanavir if it is taken without ritonavir. Alternative treatments include Kivexa and Combivir. For more information on these drugs please follow these links to Kivexa and Combivir.

For more information about atazanavir-induced hyperbilirubinaemia please follow this link.

If you decide to try this and you are still not happy or still having problems with yellowing of the skin then you can change the atazanavir altogether. To enable me to give you some suggestions of alternative medicines it would be good to get a more detailed history such as do you have any resistance? What medications have you taken before? Why did you change? How long have you been on treatment, what is your CD4 count and viral load now? What were your CD4 and viral load levels when you started treatment? Where in the world are you being treated? Any other information you feel may be useful as well.