March 14th, 2009
Sedating HIV-Infected Endoscopy Patients
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?
M. Brian Fennerty, MD
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