Stavudine-induced pancreatitis followed by lopinavir-ritonavir-induced pancreatitis: Is co-trimoxazole the culprit?
Department of Medicine I and Infectious Diseases, Christian Medical College and Hospital, Vellore, India
Department of Medicine I and Infectious Diseases, Christian Medical College and Hospital, Vellore
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Bhargava P. Stavudine-induced pancreatitis followed by lopinavir-ritonavir-induced pancreatitis: Is co-trimoxazole the culprit?.J Postgrad Med 2008;54:241-241
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Bhargava P. Stavudine-induced pancreatitis followed by lopinavir-ritonavir-induced pancreatitis: Is co-trimoxazole the culprit?. J Postgrad Med [serial online] 2008 [cited 2020 May 28 ];54:241-241
Available from: http://www.jpgmonline.com/text.asp?2008/54/3/241/41817
I read with interest the adverse drug reaction report by Harugeri et al. , regarding lopinavir-ritonavir-induced pancreatitis following stavudine-induced pancreatitis.  There are several inconsistencies in this report and certain information essential to prove their hypothesis is missing.
To begin with, the initial anti retroviral therapy should have been Zidovudine 300 mg twice daily, lamivudine 150 mg twice daily and nevirapine 200 mg once daily for two weeks followed by twice daily. This is essential as severe cutaneous and hepatic side-effects of nevirapine may be avoided by this lead in dose.
Secondly, the dose of lopinavir-ritonavir is 400/100 mg twice daily and not 200/50 mg twice daily as in this report. Hence this patient was under-dosed. Also the most plausible mechanism for pancreatitis developing after treatment with lopinavir-ritonavir is via hypertriglyceridemia.  This complication usually requires prolonged duration and is usually associated with other changes such as lipodystrophy and hence is unlikely in this patient who had received the protease inhibitors for only three weeks.  The absence of triglyceride values makes it extremely difficult to accept the relationship between the drug and the event of pancreatitis.
Thirdly, co-trimoxazole itself may lead to pancreatitis. The fact that the dose of this drug was hiked in the last admission for the treatment of pneumocystis pneumonia infection has been underplayed. It has been reported earlier that this drug may result in pancreatitis even after being used safely for several years. 
Thus, the author's assumption of the link between lopinavir-ritonavir use and pancreatitis seems untenable. In fact co-trimoxazole may be a more likely culprit in this case.
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