Nevirapine is being considered for initiation of antiretroviral therapy. In which group is the risk of serious cutaneous reactions such as Stevens-Johnson syndrome highest, making nevirapine inappropriate?

• A Men with CD4 counts below 100 cells/mm3
• B Patients already receiving rifampicin therapy
• C Patients with hepatitis B coinfection regardless of sex
• D Women with CD4 counts above 250 cells/mm3 ✓

Explanation

Nevirapine causes rash ranging from mild eruption to Stevens-Johnson syndrome, and the risk of severe hypersensitivity correlates with higher baseline CD4 counts when therapy begins. Women with CD4 counts above 250 cells/mm3 and men above 400 carry unacceptably high risk, so nevirapine should not be initiated in these groups. Low CD4 count paradoxically lowers the risk, and rifampicin actually reduces nevirapine exposure through CYP3A4 induction rather than raising cutaneous toxicity.

Reference: Katzung Basic and Clinical Pharmacology, 15th ed.

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