An ongoing dialogue on HIV/AIDS, infectious diseases,
March 1st, 2009
Sedation for Colonoscopies in HIV Patients: Debate Rages
Here’s a problem we’re grappling with:
A patient with HIV needs a colonoscopy, but is on either a ritonavir-boosted protease inhibitor or an efavirenz-based regimen.
(This must be something like 90% of HIV patients as of March 1, 2009, based on my extremely unscientific gut impression.)
For efavirenz, midazolam is contraindicated; for ritonavir, same story — or “consider therapy modification”, according to one source I found. Ditto fentanyl.
So what should be given for sedation? (Important side note: if you told me pre-1996 that this would be a critical management question for my HIV patients, I would have thought you were out of your mind.)
Lots of different views here in Boston, including:
- Give the usual meds, titrate to effect
- NEVER give midazolam with either efavirenz or ritonavir; instead, use lorazepam, etc
- Stop HIV meds 1 day in advance, then give midazolam and fentanyl
Does anyone know? Or does anyone have sufficient experience to share?
Paul E. Sax, MD
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