Tenofovir disoproxil fumarate
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Severe bone pain: 2 case reports Two patients developed severe bone pain during treatment with tenofovir disoproxil fumarate for AIDS [route not stated; not all dosages stated]. A 37-year-old man with a history of HAART started receiving tenofovir disoproxil fumarate 300mg daily as part of a new HAART regimen in January 2003. In March 2006, he experienced lower back pain and bilateral hip pain, and had difficulty walking due to bone pain; his pain worsened despite administration of oxycodone and morphine. In March 2007, zidovudine was discontinued due to peripheral neuropathy, and replaced with atazanavir and ritonavir in March 2007. Then in November, he reported severe muscle and joint pain. In January 2008, he developed worsening bone pain involving his entire body and restricting his movement. In April, a dual energy X-ray absorptiometry (DXA) scan showed severe osteoporosis. A bone scan revealed multiple chronic or subacute fractures. His calcium level was low, AP levels were elevated and his renal function was abnormal. His BMI had decreased from 19.2 kg/m2 to 18.1 kg/m2 since tenofovir disoproxil fumarate initiation. In May, HAART was changed to lamivudine/zidovudine, raltegravir, and ritonavir-boosted atazanavir; additionally, he started taking colecalciferol [vitamin D3], calcium carbonate and phosphate supplements. His bone pain had resolved in August, and he could walk without any assistance. At last follow-up, a bone DXA scan showed significant improvements in T-scores. A 48-year-old man had been noncompliant with his HAART regimens in the past. In September 2004, he started receiving HAART consisting of tenofovir disoproxil fumarate 300mg daily, lopinavir, emtricitabine and stavudine. In October 2004, emtricitabine was replaced with emtricitabine/tenofovir disoproxil fumarate [Truvada]; stavudine and lopinavir were replaced with tenofovir disoproxil fumarate and atazanavir. He had persistent hypokalaemia, and elevated serum creatinine levels and low bicarbonate levels from January 2007. In May 2008, he presented with severe rib pain on his right side. His pain spread to his ankle and chest, and his ability to walk was restricted by August. His BMI had decreased from 20 kg/m2 to 18.3 kg/m2 since tenofovir disoproxil fumarate initiation. That month, a bone DXA scan showed severe osteoporosis. By October, he reported that "everything hurts". In November, his pain had worsened, and multiple sites of abnormal uptake were evident on a nuclear medicine scan. In April 2009, he could only walk with the assistance of a cane. On 28 April, emtricitabine/tenofovir disoproxil fumarate was discontinued, and he started receiving lamivudine/abacavir, unboosted atazanavir, calcitriol, potassium chloride and phosphate. In May 2009, his Tscores had further deteriorated, and renal parenchymal disease was evident. He was diagnosed with severe osteoporosis due to tenofovir and received calcitriol, a phosphorus replacement, multivitamins, and a potassium replacement. Following the normalisation of his phosphorus levels,
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