In a recent blog post, ID expert Paul Sax raised the question of which sedatives should be used when scoping HIV-infected patients on ritonavir or efavirenz. Both antiretrovirals inhibit the CYP3A enzyme, which metabolizes one of our most commonly used sedatives, midazolam. Use of midazolam with either antiretroviral is technically contraindicated because of significant increases that occur in blood levels of midazolam. So how do we sedate our HIV-infected colonoscopy patients?
The same as we do all our endoscopy patients: We titrate midazolam for effect. In my mind, there is little reason to view this drug as “contraindicated” with ritonavir or efavirenz. Increased blood levels of midazolam should lead to adequate sedation at lower doses without the potential for over-sedation, assuming the midazolam is used appropriately — that is, infused at a low dose with a reassessment of effect and level of sedation before additional doses are given.
However, Paul noted in his blog that lorazepam (Ativan) and other drugs are sometimes substituted for midazolam in this situation or that the patient’s ritonavir is stopped the day before midazolam is used. Frankly, the mention of these practices surprised me and led me to conduct this informal poll…
What do you do when you encounter these patients?
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Brian, thanks for getting this issue out there to your GI colleagues. We have a meeting with the group in charge of policy on “conscious sedation,” and this specific question will be discussed — hope to get it resolved.
Just for the record, our HIV patients now have a projected life expectancy estimated to be decades — cancer screening recommendations that apply to HIV negative patients apply equally to them. Furthermore, the vast majority of HIV patients on antiviral therapy are receiving either efavirenz or ritonavir, so this issue of sedation for colonoscopies is a highly relevant question.
Propofol