Correspondence Prednisolone does not prevent the occurrence of nevirs Nevirapine (NVP) is a non-nucleoside reverse tran scriptase HIV-1 inhibitor. Its most frequent side-effect is the development of a rash (usually within the first 4-6 weeks) occurring in 9-32% of the patients in con- trolled clinical trials, with a 6-7% drug discontinuation rate and an incidence of Stevens-fohnson syndrome of approximately 1% [1-6]. Because NVP induces its own, hepatic metabolism, a lead-in dosing period (200 mg/day) of 2 weeks has been recommended before the full daily 400 mg dose, which is also thought to decrease the risk of rash. Prednisone has been reported in one study [7] to diminish the incidence of NVP- induced rash from 14% (10/72 patients in the historical control group) to 1.2% (1/83 prednisone-treated patients) when given during this 14 days induction pphase. Although the potential benefit of corticosteroids in preventing rash is poorly understood, our group decided to offer patients initiating NVP daily prednisolone. The present study is a retrospective ‘evaluation of the results. We identified 49 patients in our database who started ‘on NVP as part of a triple antiretroviral combination between May 1997 and March 1999. Patients were offered corticosteroid treatment from October 1998 onwards unless they had hypertension, diabetes, or acute herpes infection. Twenty-cight patients were given prednisolone 40 mg/day during the 2 weeks Icad-in period of NVP. After this induction phase, NVP was increased to 400 mg/day, and simultaneously prednisolone was discontinued. One patient was lost r0 follow-up early during the lead-in phase, 27 patients ‘were thus evaluable (nine antiretroviral naive, and 18 experienced). The mean CD4 cell count was 547/mm" (range 162-985/mm') and the mean viral load was 2.80 logy, (range < 1.3-4.80 log,,). Ten out of these 27 (37%) experienced side-effects during the first month (day 10 to day 30) of NVP therapy including one with hepatitis and renal failure, one with hypothyroidism, and eight (30%) with rash. Two of the eight developed a Stevens-Johnson syndrome. In ewo patients wich mild eruption, the side-effect disappeared while contin uing NVP; the drug was discontinued in the remaining eight patients. The outcome was favourable in all cases, including the two cases of Stevens-Johnson syndrome Interestingly, these two patients had been prescribed, by their primary care physician, a Belactam antibiotic during the NVP induction phase. Moreover, one of them, misinterpreting recommendations, started on nevirapine at a full dose of 400 mg/day. If we exclude these two cases because of potential co-factors, six out of 27 patients (22%) experienced a rash in the pred~ nisolone group. The high incidence of rash observed in the present study is in sharp conteast with the data presented by Kaspar [7]. in spite of an identical corticosteroid dosing. induced rashes It compares well with the 15-32% incidence reported in three of the major crials of NVP [1,3,4] in the absence of steroid. Of the 21 patients in our series who started on NVP without prednisolone (data not shown), two (9.5%) developed a rash, an incidence similar to that observed in another NVP clinical trial 2], again without corticosteroid. In our experience predisolone given during the lead-in phase of NVP treatment does not reduce the incidence of skin rash. A recent study from Spain [8] reported a significant reduction (from 8.5 (© 2.1%, P< 0.05) of the inci- dence of rash using a protracted escalating initial dosing of NVP (100 mg/day during the first week followed by 2 100 mg escalation dose each week up to 400 mg at the fourth week) compared with the standard lead-in regimen, Although the methodology of this study is unclear, the 2.1% incidence of NVP-associated ash is the lowest hitherto reported in the absence of corticos- teroids. Nevertheless, the risk of the development of a resistance mutation to NVP induced by exposure to subtherapeutic concentrations of the drug requires far ther evaluation, David Rey, Marialuisa Partisani, Véronique Krantz, Georgette Kempf, Margreet Nicolle, Erik de Mautort, Michelle Priester, Claudine Bernard-Hemry and Jean-Marie Lang, Centre informations et de Soins de "Immunodeficience Humaine, Cinique Medicale A, Hopitaux Universitaires, 1, place de Métal, 67091 Seasbourg Code, France. Received: 14 Joly 1999; accepted! 26 uly 1998. References 1. Corr A, Vella, de Jong MD, e lA contre trial of nevirap- Ine plas zidovudine versus zidovudine alone in p24 antige. smaemiae HIVinfected patients. AIDS 1996,10:635-641 2. Diaquila RT, Hughes MD, johnson VA, etal. Nevirapine, idovudine, and didanosine compared with zidovudine and ‘idanosine inpatients with HIV-1 fection. An ltern Med 1996 124°1024-1030. 3. Montanr SC, Ross P. Cooper, e al. A randomized, double- ‘lind trial comparing combinations of nevirapine, didanosine, and zidovudine for HIV-infected patients The INCAS tal A014 1998, 279:930-957 4. Florida Mt, Bucciandii 8, Riciardull D, et a. A randomized, ‘double-blind trial on the use of a triple combination including, nevirapine, a nonnucleoside reverse transcriptase HIV Inhibitor in antiretrviral-nave patients with advanced dis cease, AIDS 1909, 20:11-19. 5. Barnes A, Myers M. Nevirapine and rashes. Lancet 1998, 3511133, 66, Warren Kl, Boxwell DE, kim NY, Drolet 8A. Nevrapine assoc ated Stevens-Johnson syndrome. lace 1998, 351.367 7. Kaspar R Prednisone daring the induction phase of nevirapine ‘therapy appears to reduce the incidence of nevirapine as ated rash, oth Tntercence Conference on Antimicrobial Agents and Chemotherapy. San Diego, USA, 24-27 September 1396 Abstract al 8. Anton P, Soriano V, limener-Nacher |, ea. Incidence of rash ‘nd discontinuation of nevirapine using two diferent escalat lig inal doves. AIDS 1998, 135264525, 2307