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Acute Onset of Pancreatitis with Concomitant Use of Tenofovir and Didanosine

Clinical Staff Pharmacist, Department of Pharmacy, Cleveland Clinic Foundation, Cleveland, OH

Robert T Higginson, PA-C

Clinical Specialist in HIV, Virginia Commonwealth University Medical Center, Richmond, VA

Patricia Pecora Fulco, PharmD BCPS

Clinical Pharmacy Specialist in Internal Medicine/HIV; Clinical Assistant Professor, Department of Pharmacy, Virginia Commonwealth University Medical Center

Reprints: Patricia Pecora Fulco PharmD BCPS, Department of Pharmacy, Virginia Commonwealth University Medical Center, 401 N. 12th St., PO Box 980042, Richmond, VA 23298-0042, fax 804/225-3920, pgpecora{at}hsc.vcu.edu

OBJECTIVE: To report a case of pancreatitis associated with the combined use of didanosine and tenofovir.

CASE SUMMARY: A 51-year-old white man with HIV was initiated on antiretroviral therapy with didanosine 250 mg/day, tenofovir 300 mg/day, lamivudine 300 mg/day, stavudine 60 mg/day, and efavirenz 600 mg/day. Didanosine was prescribed at a reduced dosage due to the known interaction with tenofovir. Despite this dosage adjustment, the patient developed acute pancreatitis 10 weeks after antiretrovirals were initiated. Pancreatitis resolved spontaneously after antiretroviral discontinuation.

DISCUSSION: Our report of didanosine-induced pancreatitis secondary to concurrent use with tenofovir is the third reported case that utilized a reduced didanosine dosage. Five previous pancreatitis reports have been described using full-strength didanosine with tenofovir. The exact mechanism of action for this interaction is unknown. Utilizing the Naranjo probability scale to assess causality, a possible adverse drug reaction was determined.

CONCLUSIONS: Tenofovir and didanosine may be used cautiously in antiretroviral combination therapy. Reduced didanosine dosage (250 mg) should be used to reduce serum didanosine concentrations and subsequent toxicities. Practitioners should be aware that a significant drug interaction with resulting pancreatitis may occur even when a reduced dosage is prescribed.

Key Words: didanosine, pancreatitis, tenofovir

Published Online, August 31, 2004. www.theannals.com, DOI 10.1345/aph.1D616

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