HIV Drug Selector Quiz
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Viramune is a brand name for nevirapine, a non‑nucleoside reverse transcriptase inhibitor (NNRTI) used in combination antiretroviral therapy (cART) for HIV‑1 infection. It was approved in 1997, is listed on WHO essential medicines, and is known for its low cost and once‑daily dosing after a lead‑in period.
Why compare Viramune with other HIV drugs?
Prescribers often ask: "Is nevirapine still a good choice for my patient?" The answer depends on efficacy, side‑effect profile, resistance patterns, drug‑drug interactions, and special populations such as pregnant women or people with hepatitis B co‑infection. By laying out the key attributes of the most common alternatives, clinicians can match the right regimen to the right patient.
Core entities in the comparison
The analysis focuses on six primary antiretrovirals that frequently appear alongside nevirapine in guidelines:
- Efavirenz - a second‑generation NNRTI with high genetic barrier and once‑daily dosing.
- Rilpivirine - a newer NNRTI preferred for patients with low viral load (<100,000 copies/ml).
- Etravirine - a diarylpyrimidine NNRTI used mainly in salvage therapy.
- Dolutegravir - an integrase strand transfer inhibitor (INSTI) with a high barrier to resistance.
- Zidovudine - a nucleoside reverse transcriptase inhibitor (NRTI) that forms the backbone of many older regimens.
- WHO HIV Treatment Guidelines - the global policy framework that ranks these drugs for first‑line, second‑line, and special‑population use.
Key attributes compared
| Drug | Class | Typical Dose | Key Advantage | Major Safety Concern | Resistance Barrier |
|---|---|---|---|---|---|
| Nevirapine | NNRTI | 200mg bid (lead‑in) → 200mg daily | Low cost, wide availability | Hepatotoxicity, severe rash | Low |
| Efavirenz | NNRTI | 600mg daily | High potency, once daily | Neuropsychiatric effects | Moderate |
| Rilpivirine | NNRTI | 25mg daily (with food) | Fewer CNS effects | Requires low viral load & food intake | Moderate |
| Etravirine | NNRTI | 200mg bid | Effective against NNRTI‑resistant virus | Rash, nausea | High (in salvage) |
| Dolutegravir | INSTI | 50mg daily | Very high barrier to resistance | Weight gain, possible neural‑tube defects (early pregnancy) | Very high |
| Zidovudine | NRTI | 300mg bid | Long‑standing safety data | Bone‑marrow suppression, anemia | Low |
Clinical scenarios where Nevirapine shines
Despite its lower resistance barrier, nevirapine remains a viable option in several contexts:
- Resource‑limited settings: the drug’s price (<$5/month in many generic markets) and storage stability make it a mainstay of national programs.
- Pregnancy: WHO recommends nevirapine as part of a first‑line regimen for women who start treatment after 14weeks, provided liver enzymes are normal.
- Co‑administration with rifampicin: nevirapine’s metabolism via CYP3A4 tolerates the enzyme‑inducing effect of rifampicin better than efavirenz, avoiding the need for dose escalation.
When alternatives are preferable
If a patient presents any of the following, clinicians should look beyond nevirapine:
- Pre‑existing liver disease - hepatitis B or C raises the risk of severe hepatotoxicity; efavirenz or dolutegravir are safer.
- History of rash - especially Grade3/4; switching to rilpivirine or an INSTI reduces recurrence.
- High baseline viral load (>100,000 copies/ml) - efavirenz or dolutegravir achieve faster suppression.
- Need for high resistance barrier - treatment‑naïve patients in areas with transmitted NNRTI resistance benefit from dolutegravir or boosted protease inhibitors.
Pharmacokinetic and drug‑interaction snapshot
Understanding metabolism helps avoid hidden failures. Nevirapine induces CYP3A4 and CYP2B6, which can lower concentrations of co‑prescribed drugs such as certain antimalarials, hormonal contraceptives, and some statins. Efavirenz shares similar induction but adds CYP2C19 inhibition. Rilpivirine’s absorption is food‑dependent, while dolutegravir’s effect is modestly reduced by polyvalent cations (e.g., calcium supplements).
Resistance patterns and cross‑resistance
Mutations K103N, Y181C, and G190A render nevirapine ineffective and often confer cross‑resistance to efavirenz and rilpivirine. Etravirine retains activity against many of these mutants, which is why it stays in salvage regimens. Dolutegravir’s signature mutations (R263K, G118R) are rare, giving it a distinct advantage when NNRTI resistance is documented.
Cost and accessibility considerations
In high‑income countries, generic nevirapine costs roughly US$0.12 per tablet, while dolutegravir (even generic) runs about US$1.50 per tablet. Rilpivirine is priced at US$0.80‑1.00. For programs funded by international donors, the lower price of nevirapine often tips the balance, especially when combined with cost‑effective NRTI backbones such as lamivudine + tenofovir.
Practical prescribing checklist
Before starting nevirapine, run through this quick list:
- Baseline ALT/AST and bilirubin - must be <2×ULN.
- Screen for active hepatitis B/C - consider alternative if present.
- Check for prior severe rash or hypersensitivity.
- Confirm no contraindicated drugs (e.g., certain anticonvulsants that heavily induce CYP3A4).
- Educate patient on early signs of liver injury (jaundice, dark urine) and rash; advise immediate reporting.
Related concepts and next‑step topics
The discussion of nevirapine ties into broader subjects such as:
- Fixed‑dose combination (FDC) tablets - e.g., nevirapine/lamivudine/zidovudine.
- Therapeutic drug monitoring (TDM) for NNRTIs.
- Management of HIV in pregnancy - WHO guidelines vs. national protocols.
- Transitioning from NNRTI‑based to INSTI‑based regimens.
- Adherence support tools in low‑resource settings.
Readers interested in any of those can explore dedicated articles that dive deeper into dosing strategies, monitoring, and policy implications.
Frequently Asked Questions
Is nevirapine safe to use during pregnancy?
The WHO recommends nevirapine for pregnant women who start therapy after the first trimester, provided liver function tests are normal. Early‑pregnancy exposure carries a small risk of neural‑tube defects, so many clinicians prefer dolutegravir or efavirenz after counseling.
How does the cost of nevirapine compare to dolutegravir?
Generic nevirapine costs roughly US$0.12 per tablet, whereas generic dolutegravir is about US$1.50 per tablet. In resource‑limited programs, the price gap can be decisive, especially when paired with cheap NRTI backbones.
What are the most common side effects of nevirapine?
Rash (up to 10% of patients) and mild to moderate elevations in liver enzymes are the hallmarks. Severe hepatic toxicity occurs in about 1% and usually presents within the first 12 weeks of therapy.
Can nevirapine be taken with rifampicin for TB co‑infection?
Yes. Nevirapine’s metabolism is less affected by rifampicin than efavirenz, so dose adjustment is usually unnecessary. However, close monitoring of viral load and liver enzymes is advised.
When should I switch a patient from nevirapine to another NNRTI?
Switch is warranted if the patient develops Grade3/4 rash, ALT/AST >5×ULN, or if baseline viral load exceeds 100,000 copies/ml and rapid suppression is needed. Rilpivirine or efavirenz are typical alternatives, depending on CNS tolerance.
How does resistance to nevirapine develop?
Nevirapine selects for NNRTI‑coding mutations such as K103N, Y181C, and G190A. These arise quickly if drug levels fall below the inhibitory concentration, which is why adherence counseling is critical during the lead‑in period.
Is therapeutic drug monitoring needed for nevirapine?
Routine TDM is not standard, but measuring plasma concentrations can help in cases of suspected malabsorption, drug interactions, or unexplained treatment failure.
