Clinical practice guidelines recommend starting and maintaining antiretroviral treatment (ART) in all patients diagnosed with human immunodeficiency virus (HIV) infection, regardless of the number of CD4 T lymphocytes, with the aim of improving their health, reducing the pro-inflammatory state and lowering the prevalence of associated diseases, preserving or trying to improve immune function, and reducing HIV transmission in the population.1
Based on previous recommendations, the issue is more serious when unexpected clinical situations occur that prevent oral ART from being continued. Under such circumstances, the most recent clinical practice guidelines, including those from the United States, propose temporary solutions such as perioperative suspension for less than two days, sequencing to liquid formulations or ART regimens that can be crushed and are compatible for administration via enteral routes.2 But what happens when the oral route is totally inaccessible even using a nasogastric tube? We report the following case in response to this clinical issue.
Our 55-year-old female patient has been living with HIV since 2000. She was on her third line of ART: she was started with darunavir boosted with ritonavir and emtricitabine/tenofovir disoproxil fumarate (DRV/r + FTC/TDF) which was later simplified to dolutegravir/abacavir/lamivudine (DTG/ABC/3TC) and, since December 2020, simplified to dual therapy in a regimen based on non-nucleoside reverse transcriptase inhibitors (NNRTI) with dolutegravir/rilpivirine (DTG/RPV). She had not suffered any virological failure, but we had no more information as she had been transferred from another centre where the diagnosis had been made. Despite not having a documented study of resistance mutations, the current ART raised no suspicion of mutations in reverse transcriptase as the patient maintained adequate immunovirological control in the six months prior to admission (CD4 T lymphocytes: 501/mm3 and HIV viral load <40 cp/mL) with an NNRTI-based ART.
Her other previous medical history included chronic infection with the hepatitis C virus (HCV), treated and in sustained virologic response with no signs of liver disease, and she was immunised against the hepatitis B virus (HBV). In September 2023, after a wasting syndrome, jaundice and diarrhoea, she was diagnosed with stage IIB pancreatic adenocarcinoma, for which she began neoadjuvant chemotherapy and in May 2024, she underwent surgery, performing a pancreaticoduodenectomy with partial resection of the lateral wall of the portal vein, with adequate radiological and biological response. Postoperatively the patient had a nasogastric tube with free drainage, which was producing a high output. The enteral approach was not an option, as all oral contents were removed by the nasogastric tube and the surgery did not allow another interventional approach. Therefore, in anticipation of the situation persisting for some time and after three days of omission of the previous oral ART, we considered the possibility of sequencing to parenteral ART. We went ahead, administering cabotegravir (CAB) + RPV intramuscularly, after weighing up the risk/benefit and in consensus with the patient, who maintained adequate immunovirological control. She did not develop any related side effects.
There are some antiretroviral medications available in parenteral formulations, such as zidovudine, enfuvirtide, ibalizumab, CAB and RPV. The long-acting CAB + RPV combination is approved as a complete regimen for the treatment of HIV and is included as a simplification option in guidelines such as the Spanish Grupo de Estudio del SIDA (GESIDA) [AIDS Study Group] in patients without previous virological failures, without known or suspected resistance mutations to integrases or to NNRTI, who, in addition, have maintained virological suppression in the previous six months with stable oral ART.3 We still do not have sufficient scientific evidence to recommend it in situations such as the one described in this manuscript.2,4–6
Studies such as ATLAS and FLAIR demonstrated the efficacy and safety of the aforementioned combination both in monthly and two-monthly administration, which in turn causes less ART-related toxicity by reducing the number of components and minimising the potential development of resistance in patients with suboptimal adherence to standard oral ART.4,7,8
Considering all this, we believe that the combination of CAB + RPV is a robust and safe regimen. It would allow active and effective ART to be maintained in a complex scenario such as the impossibility of enteral feeding. It is an alternative to standard treatment, avoiding potential complications derived from an interruption of ART.
FundingWe confirm that no funding was received from any organisation or institution for the writing of this manuscript.
Conflicts of interestThe authors declare that they have no conflicts of interest.
We would like to thank Dr Fuentes and Dr Vargas, surgeons who trusted us to collaborate in the case and try to contribute the best of ourselves to our patients.
