Excessive Neurotoxicity With ABVD When Combined With Protease Inhibitor–Based Antiretroviral Therapy in the Treatment of AIDS-Related Hodgkin Lymphoma

Hodgkin lymphoma (HL) is the second most common non–AIDS-defining malignancy among persons infected with HIV, and its incidence might be increasing in the current era of combination antiretroviral therapy (cART). With the immune reconstitution afforded by cART, most patients are now able to tolerate the standard-dose chemotherapies administered to immunocompetent individuals with HL, such as ABVD (doxorubicin/bleomycin/vinblastine/dacarbazine). Antiretroviral therapy is commonly prescribed concomitantly with chemotherapy in the treatment of AIDS-related malignancies. However, little is known about the pharmacokinetic consequences of combined therapy. In particular, the potential for excessive vinca alkaloid–associated toxicity is significant, given the metabolism of drugs such as vinblastine by the 3A4 isoenzyme of the cytochrome P450 system and the inhibition of this isoenzyme by protease inhibitors. We report 3 patients who experienced severe vinblastine-associated neurotoxicity during concomitant treatment with ritonavir-boosted antiretrovirals. The implications for the treatment of patients with HL in the current era of cART are discussed.