ACUTE PANCREATITIS DUE TO PROTEASE INHIBITOR CONTAINING REGIMEN TREATED WITH PLASMAPHERESIS

JP Routy¹, S Bruce¹, MR Boulassel¹, GRH Smith¹, DW Blank², BM Gilfix^2
1Immunodeficiency Service; ²Division of Clinical Biochemistry, McGill University Health Centre, Montreal, Quebec

Objective: Lipid changes are a well-recognized side effect of long-term treatment with protease inhibitors (PIs). Here we report a case of severe hypertriglyceridemia complicated by acute pancreatitis treated by plasmapheresis in an HIV-1 patient treated with a boosted PI regimen containing ritonavir and indinavir.
Case presentation: A 35-year-old HIV-1 positive male was in remission from a high-grade non-Hodgkin lymphoma after the completion of six cycles of CHOP. Over the past 3 years, he was successfully treated with a combination of d4T (40 mg b.i.d.), 3TC (150 mg b.i.d.) and indinavir (800 mg t.i.d.). In response to an increase of his HIV RNA plasma level, which was detectable for the first time (5040 copies/mL with CD4=101x10⁶/L), ritonavir (400 mg b.i.d.) was added to the same therapy regimen with a dose reduction of indinavir (400 mg b.i.d.). Three weeks later, the patient developed nausea, severe abdominal pain, a distended abdomen and presented abnormal laboratory test values: total cholesterol (27.1 mmol/L, reference value 3.8-5.2), lipase (864 U/L, reference value 8-57), amylase (238 U/L, reference value 20-130) and triglycerides (62.9 mmol/L, reference value 0.0-2.3). A CT scan of the abdomen confirmed the presence of stage C acute pancreatitis. Anti-HIV medication was immediately held, and plasmapheresis was performed. Symptoms were alleviated after the first plasmapheresis and the laboratory values returned to their normal ranges. The patient fully recovered after one week of treatment with dT4, 3TC and indinavir (800 mg t.i.d.) regimens.
Conclusion: This is the first case reporting acute pancreatitis due to ritonavir-indinavir related hypertriglyceridemia treated by plasmapheresis. This case stresses the importance of closely monitoring total cholesterol and triglyceride levels during the first month of therapy in patients initiating ritonavir containing regimens. This case also illustrates the use of plasmapheresis to treat acute pancreatitis in the setting of ritonavir-induced hypertriglyceridemia.