Association of Prenatal and Postnatal Exposure to Lopinavir-Ritonavir and Adrenal Dysfunction Among Uninfected Infants of HIV-Infected Mothers

Albane Simon, MD;
Josiane Warszawski, MD, PhD;
Dulanjalee Kariyawasam, MD;
Jerome Le Chenadec, MSc;
Valerie Benhammou, PhD;
Paul Czernichow, MD;
Frantz Foissac, MD;
Kathleen Laborde, PhD;
Jean-Marc Tréluyer, MD, PhD;
Ghislaine Firtion, MD;
Inès Layouni, MD;
Martine Munzer, MD;
Françoise Bavoux, MD;
Michel Polak, MD, PhD;
Stéphane Blanche, MD
for the ANRS French Perinatal Cohort Study Group

Context Lopinavir-ritonavir is a human immunodeficiency virus 1 (HIV-1) protease inhibitor boosted by ritonavir, a cytochrome p450 inhibitor. A warning about its tolerance in premature newborns was recently released, and transient elevation of 17-hydroxyprogesterone (17OHP) was noted in 2 newborns treated with lopinavir-ritonavir in France.

Objective To evaluate adrenal function in newborns postnatally treated with lopinavir-ritonavir.

Design, Setting, and Participants Retrospective cross-sectional analysis of the database from the national screening for congenital adrenal hyperplasia (CAH) and the French Perinatal Cohort. Comparison of HIV-1–uninfected newborns postnatally treated with lopinavir-ritonavir and controls treated with standard zidovudine.

Main Outcome Measures Plasma 17OHP and dehydroepiandrosterone-sulfate (DHEA-S) concentrations during the first week of treatment. Clinical and biological symptoms compatible with adrenal deficiency.

Results Of 50 HIV-1–uninfected newborns who received lopinavir-ritonavir at birth for a median of 30 days (interquartile range [IQR], 25-33), 7 (14%) had elevated 17OHP levels greater than 16.5 ng/mL for term infants (>23.1 ng/mL for preterm) on days 1 to 6 vs 0 of 108 controls having elevated levels. The median 17OHP concentration for 42 term newborns treated with lopinavir-ritonavir was 9.9 ng/mL (IQR, 3.9-14.1 ng/mL) vs 3.7 ng/mL (IQR, 2.6-5.3 ng/mL) for 93 term controls (P < .001). The difference observed in median 17OHP values between treated newborns and controls was higher in children also exposed in utero (11.5 ng/mL vs 3.7 ng/mL; P < .001) than not exposed in utero (6.9 ng/mL vs 3.3 ng/mL; P = .03). The median DHEA-S concentration among 18 term newborns treated with lopinavir-ritonavir was 9242 ng/mL (IQR, 1347-25 986 ng/mL) compared with 484 ng/mL (IQR, 218-1308 ng/mL) among 17 term controls (P < .001). The 17OHP and DHEA-S concentrations were positively correlated (r = 0.53; P = .001). All term newborns treated with lopinavir-ritonavir were asymptomatic, although 3 premature newborns experienced life-threatening symptoms compatible with adrenal insufficiency, including hyponatremia and hyperkalemia with, in 1 case, cardiogenic shock. All symptoms resolved following completion of the lopinavir-ritonavir treatment.

Conclusion Among newborn children of HIV-1–infected mothers exposed in utero to lopinavir-ritonavir, postnatal treatment with a lopinavir-ritonavir–based regimen, compared with a zidovudine-based regimen, was associated with transient adrenal dysfunction.

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