A case of delayed hepatotoxicity in a patient taking Triumeq

ABSTRACT

Background: A 37-year- old man was diagnosed with HIV-1 in November 2018, following a negative test in July 2018. Baseline HIV viral load was 56882 cps/ml and CD4 610 cells/mm3 (32%). HLA B5701 was negative and genotype showed wild-type virus. Baseline ALT was 54 IU/L but this was felt to be related to recent seroconversion. He was commenced on abacavir/lamivudine/dolutegravir (Triumeq) and achieved full viral suppression after 4 weeks. Method: Over the course of 2019, his ALT ranged from 40-150 IU/L with associated occasional rises in AST to around 80 IU/L;bilirubin, ALP and GGT remained within normal limits. He reported no other prescribed or over the counter medication including gym supplements, steroid use or recreational drugs and alcohol consumption was <7 units/week. Extensive investigation for causes of transaminitis were all within normal ranges/negative and hepatic ultrasound was normal. We referred him to hepatology and continued monthly liver tests, pending review. His transaminitis worsened and by Nov 2020 ALT 501 IU/L/ AST 200 IU/L and an urgent liver biopsy was arranged. By Dec 2020 ALT 997 IU/L, AST 316 IU/L and we decided to stop his Triumeq as there was no other explanation for his liver inflammation. Results: The patient later disclosed the use of anabolic steroids during 2020 due to Covid-19 gym closures but he had stopped these in November. His transaminases improved immediately upon cessation of Triumeq and within 14 days ALT was 354 and AST 130. Conclusion: Liver biopsy histopathology showed changes in keeping with drug-induced liver injury (DILI) that was not consistent with typical patterns seen with anabolic steroid use. Given other case reports of INSTI-associated DILI with a possible class effect, as well as omeprazole use, we recommenced ART with TDF/lamivudine/doravirine. The patient continues to use anabolic steroids. ALT/AST continue to fall and the patient remains in follow-up. We report a case of probable delayed hepatotoxicity after 2 years in a patient taking Triumeq. Late ART-associated DILI should be considered in the context of worsening transaminitis.