of the Hip with Truvada

Joey Wu, Arnold Henry MD Indiana University School of Medicine

ABSTRACT EXAMINATION DISCUSSION We report a previously healthy 37 year Initial encounter: Full strength and range of motion. Tenderness to palpation over Truvada has been linked to decreased old male patient who presents with hip the proximal quadricep muscles. Negative FABER test but mild pain at the greater density and increased risk for pain and decreased range of motion trochanter. Positive Obers test for IT band tightness and pain bone necrosis due to the ingredient Tenofovir disoproxil fumarate1 Medical history only significant for X-ray imaging after 1 year of treatment with oral diclofenac, home exercise, and Truvada prophylaxis for sexual physical therapy shows sclerosis and flattening of the left femoral head, consistent Discontinue Truvada and begin intercourse with HIV positive partner with avascular necrosis with early secondary degenerative changes (Figure 1.1 – Descovy (Tenofovir alafenamide) as it 6/5/2019) can improve bone health1 Imaging shows Avascular necrosis of the left femoral head and worsening Patient switched from Truvada to Descovy Sept 2019. Hip pain stabilized but patient Differentials: acute injury, steroid use since diagnosis continued to experience stiffness and restricted range of motion. Imaging: Progressive avascular necrosis of the Left femoral head loss and AVN has been Patient was followed up Feb 2020, with worsening pain that is now affecting the reported with Truvada use lower leg, especially when sleeping or standing. Physical exam showed abnormal Treatment: physical therapy, NSAIDs gait with left lower extremities in slight internal rotation; left hip pain with spinal and possible future hip replacement INTRODUCTION forward flexion; decreased external rotation with FABER and positive log roll. Foot inserts were prescribed and ankle strengthening exercise were recommended. Our patient shows progressive necrosis of the left femoral head even Tenofovir disoproxil fumarate (TDF) Patient presented for 6 month follow up in Aug 2020 with worsening left hip pain, after discontinuing Truvada and is associated with bone mineral deep aching that radiates to the groin. He is antalgic favoring the right, noticeable beginning Descovy with NSAIDs and density loss (lower T score on atrophy of the left quadriceps, restricted range of motion on FABER and FADIR, and physical therapy DEXA scan compared to other mild pain with Log roll test. Pelvic/hip X-rays results significant for treatment options)1 progressive/worsening femoral head collapse with severe joint space narrowing and Bone DEXA scan could be considered bone on bone contact. to assess his overall bone health Bone density improved when patients switched from TDF to TAF DIAGNOSIS CONCLUSIONS (tenofovir alafenamide fumarate)2 Truvada can cause avascular necrosis The imaging results and clinical symptoms are consistent with left avascular of the femoral head in patients without There are ongoing class action necrosis of the hip/femoral head. lawsuit from the AIDS foundation previous health risks for decreased bone health/density against Gilead, the drug maker of Patient does not have any other significant histories or medication use that is Truvada and Descovy, regarding associated with avascular necrosis of the femoral head aside from Truvada use the bone and injuries from Disease progression could be refractory to discontinuing Truvada and Truvada use He is managed with physical therapy and NSAIDs PRN. initiating Descovy

CASE HISTORY Physical therapy and NSAIDs may not be sufficient in controlling symptoms 37-year-old gay male who is HIV REFERENCES negative in a monogamous relationship with male with HIV viral 1). Mccomsey GA, Lupo S, Parks D, load undetectable presents with Poggio MC, Wet JD, Kahl LP, et al. recurrent anterior left hip/quadriceps Switch from tenofovir disoproxil pain fumarate combination to dolutegravir plus rilpivirine improves parameters of Started taking Truvada in Jan 2015 Fig 1.1 Left Hip/Pelvic XR Fig 1.2 Right Hip/Pelvic XR Fig 1.3 Hip/Pelvic XR bone health. AIDS. with desire to decrease viral 2018Feb1;32(4):477–85. transmission risk with his partner 2). Maggiolo F, Rizzardini G, Raffi F, Diagnosed with IT band syndrome in Pulido F, Mateo-Garcia MG, Molina J- Apr 2018. Pain did not improve with M, et al. Bone mineral density in home exercise and oral Diclofenac, a virologically suppressed people aged 6-week course of physical therapy 60 years or older with HIV-1 switching from a regimen containing tenofovir Patient received X-ray of pelvic, disoproxil fumarate to an elvitegravir, bilateral hips, lumbar spine with 4 cobicistat, emtricitabine, and tenofovir views Jun 2019. Imaging significant for alafenamide single-tablet regimen: a Fig 2.1 Left Hip/Pelvic XR Fig 2.2 Right Hip/Pelvic XR Fig 2.3 Hip/Pelvic XR avascular necrosis of the left hip. multicentre, open-label, phase 3b, randomised trial. The Lancet HIV. 2019Oct6;6(10).