Sedation Interactions with Multiple Anti-Retroviral Drugs

Genvoya® contains four medications in one dose for the treatment of HIV. Tenofovir and emtricitabine are inhibitors of a viral enzyme called reverse transcriptase, necessary for retroviruses to replicate inside a host cell. Elvitegravir is an integrase inhibitor, blocking viral access into the cell, and
Cobicistat is a liver enzyme inhibitor designed to increase the bioavailability of the other medications. With such a complex series of interactions, is a patient taking Genvoya a candidate for oral sedation?

A DOCS Education member writes:

I have a 37-year-old male patient taking Genvoya for HIV. He is requesting sedation for his dental treatment. The drug is a combination of elvitegravir, cobicistat, emtricitabine, and tenofovir. This is a new combination drug that came out in November. As I understand it, the only drug here that would be a problem is the cobicistat since we don't actually have any protease inhibitors in the patient's system and the others aren't CYP3A inhibitors. That said, since I don't do IV sedation, if this person is to be treated in my office, would having a dental anesthesiologist in to do his sedation while I focus on the dental treatment be the recommendation here? Thanks.

Dr. Anthony S. Feck, DOCS Education Dean of Faculty, responds:

Based on what I have read, this patient can be treated with oral conscious sedation in an outpatient setting using appropriate monitoring (unless the patient's HIV condition is at an advanced state placing them at a ASA IV level, or the patient has other medical conditions or social habits that you do not list in your post). That being said, if you would feel more comfortable using a dental anesthesiologist to perform the sedation and monitoring, there is certainly nothing wrong with that.

If you use OCS, forego the diazepam the night before and use Incremental Protocol #3 or #4 lorazepam or lorazepam/hydroxyzine).

The DOCS education member responds:

Thank you, Dr. Feck. The lorazepam protocol was my second thought, and this will most likely be a longer appointment. Immune status is reasonable w/ viral load undetectable and CD4+ slightly over 250. My concern with the lorazepam protocols is that this is an extremely anxious patient (a simple exam was a challenge for him, periodontal charting was not going to happen) and my experience with lorazepam is that it doesn't work nearly as well as triazolam. If there are any suggestions for better results with the lorazepam protocols I'd love to hear them.

Dr. Feck adds:

While lorazepam doesn't have the potency or efficacy of triazolam dose-for-dose, you can achieve equivalent CNS depression with larger doses. It may take you up to 90 minutes to achieve this equivalent level of sedation. Also, if you combine a single dose of hydroxyzine with your incremental dosing of lorazepam, the onset of action as well as the total overall dose of lorazepam will be reduced.

Hope this helps.

The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.