ARV Adverse Effects & Drug Classes

  • Frequent effects (events expected in at least 10% of treated PLWH)(bold-black)
  • Severe effects (events that can put a person's life at risk and represent a medical emergency)(red)
  • Neither frequent nor severe effects (black)

NRTIs

Drug Adverse effect(s)

ABC

Rash
Nausea*
Diarrhoea*
IHD
*Systemic hypersensitivity syndrome (HLA B*57:01 dependent)

ZDV(ii)

Nail pigmentation
Nausea
Steatosis
Myopathy
Rhabdomyolysis
Lipoatrophy
Dyslipidaemia
Hyperlactataemia
Anaemia

3TC  
FTC  ↓ plasma lipids
TDF(iii) Hepatitis
↓ BMD
Osteomalacia
↑ Fractures risk
↓ eGFR
Fanconi syndrome

↓ plasma lipids
TAF(iii)

Weight increase

 

* Refers to effects seen in relation to hypersensitivity reactions

NNRTIs

Drug Adverse effects(s)
EFV

Rash
Hepatitis
Depression
Sleep disturbances
Headache
Suicidal ideation
Dyslipidaemia
Gynaecomastia
Plasma 25 (OH) vitamin D

ETV

Rash

NVP Rash*
Hepatitis*
*Systemic hypersensitivity (CD4 count and gender dependent)
RPV Rash
Hepatitis
↓ eGFR(iv)
Depression
Sleep disturbance
Headache
DOR  

 

* Refers to effects seen in relation to hypersensitivity reactions

PIs

Drug

Adverse Effect(s)

ATV(v)

Nausea and Diarrhoea(vii)
Hyperbilirubinaemia
Jaundice
Cholelithiasis
↓ eGFR
Nephrolithiasis
Dyslipidaemia

DRV(v) Rash
Nausea and Diarrhoea(vii)
IHD
Nephrolithiasis
Dyslipidaemia
LPV Nausea and Diarrhoea(vii)
IHD
↓ eGFR
Dyslipidaemia

Boosting

Drug Adverse Effect(s)
RTV Nausea and Diarrhoea
↓ eGFR(iv)
Dyslipidaemia
COBI

Nausea and Diarrhoea
↓ eGFR(iv)
Dyslipidaemia

FI

Drug Adverse effect(s)
ENF Injection nodules
Hypersensitivity

INSTI

Drug Side effect(s)
RAL Nausea
Myopathy 
Rhabdomyolysis
Sleep disturbance
Headache
Systemic hypersensitivity syndrome(viii)
Weight increase
DTG

Rash
Nausea
eGFR(iv) 
Sleep disturbance
Headache
Systemic hypersensitivity syndrome (<1%)
Weight increase

EVG/c

Nausea
Diarrhoea
↓ eGFR(iv)
Sleep disturbance
Headache 
Weight increase

BIC

↓ eGFR(iv)
Sleep disturbance
Headache 
Weight increase

CCR5 Inhibitor

Drug Side effect(s)
MVC Hepatitis

 

  1. "Frequent effects" (events expected in at least 10% of treated PLWH), in bold
    "Severe effects" (events that can put a person's life at risk and represent a medical emergency), in red
    "Neither frequent nor severe effects", in black
  2. Still available, but generally not recommended due to toxicity
  3. TDF has been the classical prodrug of tenofovir. TAF has lower tenofovir-related kidney and bone adverse effects, but long-term experience is lacking, see Kidney Disease, ARV-associated Nephrotoxicity, and Bone Disease
  4. Due to inhibition of renal tubular creatinine secretion without affecting glomerular filtration itself
  5. ATV can be used unboosted, or boosted with low-dose RTV or COBI ATV-related adverse effects are more common with boosting. DRV can be used boosted with low-dose RTV or COBI. Both low-dose RTV and COBI as boosters may cause minor digestive problems and lipid increases (low-dose RTV more than COBI). IHD reported with ritonavir-boosted DRV only (no data with cobicistat-boosted DRV, although lipid effects lower)
  6. Still available but seldom used. Requires RTV-boosting
  7. Frequency and severity differs between individual ARVs
  8. DRESS syndrome reported, but currently in only 6 cases

Notes:

  • The adverse effects listed in the table above are not exhaustive, but represent the most important effects with a likely causal relation. Nausea, diarrhoea and rash are frequently observed in persons on ART, and these symptoms are indicated in the table for drugs where clinical experience suggests a possible causal link
  • D4T, ddI, FPV, IDV, SQV and TPR removed. Please refer to EACS v9.1 for details, http://www.eacsociety.org/files/2018_guidelines-9.1-english.pdf

See online video lecture Adverse Effects and Monitoring of ART from the EACS online course Clinical Management of HIV