Efavirenz: A review of the epidemiology, severity and management of neuropsychiatric side-effects

Abstract

South Africa has the highest proportion of HIV-positive people in the world. HIV cannot be cured; however, there are several major classes of drugs used in its management. Efavirenz is one such agent of the class non-nucleoside reverse transcriptase inhibitors which inhibits the replication of the virus. Efavirenz is associated with causing neuropsychiatric side-effects (NPSEs), with almost 50% of patients experiencing at least one NPSE while on treatment. The NPSEs tend to occur within the first few days of initiation of therapy and resolve spontaneously within the first 4 - 6 weeks, with the most commonly reported being dizziness, insomnia, headache, abnormal dreams and impaired concentration. The plasma level of efavirenz and genetic polymorphisms are thought to play a role in the development of such NPSEs. NPSEs need to be treated according to severity. If necessary, efavirenz may be replaced with nevirapine or lopinavir/ritonavir. It should be remembered that nevirapine may also produce some severe side-effects such as skin abnormalities and hepatotoxicity. The monitoring of patients receiving efavirenz therapy should be ongoing, with those with a history of mental illness requiring closer monitoring than others.