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03.03 management of patients on antiretroviral drugs changi

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David Ngogoyo

This document provides guidance on changing or stopping antiretroviral therapy (ART) in a rational manner. It describes the main reasons for altering a patient's ART regimen as drug toxicity, interactions, or treatment failure. It discusses how to diagnose and manage common adverse drug reactions and interactions. It emphasizes the importance of assessing adherence before changing a patient's failing regimen and consulting national treatment guidelines and experts when making decisions about second-line therapy.

Saúde e medicina
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Module 3 Unit 3: Changing/stopping ART A Rational Approach to a Complicated Subject
Objectives ,[object Object],[object Object],[object Object],[object Object]
Three Main Reasons for Altering a Patient’s ARV Drug Regimen: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other reasons for altering a patient’s regimen ,[object Object],[object Object]
1. Drug Toxicity and Intolerance ,[object Object],[object Object],[object Object],[object Object],[object Object]
ARV Drug Class Adverse Effects ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Common “Mild” Side Effects ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Common “Mild” Side Effects ,[object Object],[object Object],[object Object],[object Object]
Rare, potentially serious ADRs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Toxicity: Anticipate ,[object Object],[object Object],[object Object]
Management of Adverse Drug Effects ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
A Rational Approach to the Management of Serious Side Effects Refer to “The National Clinical Manual for ARV Providers”
Rash ,[object Object],[object Object],[object Object]
Case Study - Rash ,[object Object],[object Object],[object Object]
Hepatotoxicity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Study - Hepatotoxicity ,[object Object],[object Object]
Continued… ,[object Object],[object Object],[object Object],[object Object],[object Object]
Hematological Toxicity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case Study – Hematological Toxicity ,[object Object],[object Object],[object Object],[object Object]
Peripheral Neuropathy ,[object Object],[object Object],[object Object],[object Object],[object Object]
Case Study - Neuropathy ,[object Object],[object Object],[object Object],[object Object]
Continued… ,[object Object],[object Object],[object Object]
Pancreatitis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Late Toxicity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Late Toxicity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of late toxicity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
2. Drug Interactions It is not possible to remember all the possible drugs interactions with ARV Drugs Refer to “The National ARV Guidelines”
Main Problems ,[object Object],[object Object],[object Object],[object Object]
1. Blood levels of ARVs Increased or Decreased ,[object Object],[object Object],[object Object]
TB Drugs ,[object Object],[object Object],[object Object],[object Object]
2. Reduction/increase in concentrations of other drugs (making them ineffective/toxic) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
3. Additive/Overlapping Toxicities ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
4. Incompatible ARV Drugs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Minimizing Drug Interactions ,[object Object],[object Object],[object Object],[object Object],[object Object]
3. Treatment Failure Refer to “The National Clinical Manual for ARV Providers”
Changing to 2 nd line Regime ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosing Treatment Failure ,[object Object],[object Object],[object Object],[object Object],Treat OIs Assess adherence Assess CD4 Count if possible
Diagnosing Treatment Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnosing Treatment Failure ,[object Object],[object Object],[object Object],[object Object],[object Object]
Immune Reconstitution Inflammatory Syndrome (IRIS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object]

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Unit 2 mtct and prevention strategies
Unit 2 mtct and prevention strategiesUnit 2 mtct and prevention strategies
Unit 2 mtct and prevention strategies
 
Unit 4 care of the hiv infected mother
Unit 4 care of the hiv infected motherUnit 4 care of the hiv infected mother
Unit 4 care of the hiv infected mother
 
Unit 6 infant feeding and pmtct
Unit 6 infant feeding and pmtctUnit 6 infant feeding and pmtct
Unit 6 infant feeding and pmtct
 
Unit 1 hiv and reproductive health
Unit 1 hiv and reproductive healthUnit 1 hiv and reproductive health
Unit 1 hiv and reproductive health
 
Unit 5 drug regimens for pmtct
Unit 5 drug regimens for pmtctUnit 5 drug regimens for pmtct
Unit 5 drug regimens for pmtct
 
Unit 3 counseling for pmtct
Unit 3 counseling for pmtctUnit 3 counseling for pmtct
Unit 3 counseling for pmtct
 
Module 10 hiv and aids legal and ethical issues gsn
Module 10 hiv and aids legal and ethical issues gsnModule 10 hiv and aids legal and ethical issues gsn
Module 10 hiv and aids legal and ethical issues gsn
 
Module 9 adherence & psychosocial counselling
Module 9 adherence & psychosocial counsellingModule 9 adherence & psychosocial counselling
Module 9 adherence & psychosocial counselling
 
Module 7 prevention of hiv
Module 7 prevention of hivModule 7 prevention of hiv
Module 7 prevention of hiv
 
Module 5 comprehensive care gsn
Module 5 comprehensive care gsn Module 5 comprehensive care gsn
Module 5 comprehensive care gsn
 
Module 8 nutrition and hiv 2
Module 8 nutrition and hiv 2Module 8 nutrition and hiv 2
Module 8 nutrition and hiv 2
 
Module 4 hiv infection & art in children
Module 4 hiv infection & art in childrenModule 4 hiv infection & art in children
Module 4 hiv infection & art in children
 
Participants workbook
Participants workbookParticipants workbook
Participants workbook
 
Participants notes
Participants notesParticipants notes
Participants notes
 
Indicators manual
Indicators manualIndicators manual
Indicators manual
 
Facilitators workbook
Facilitators workbookFacilitators workbook
Facilitators workbook
 
Facilitators guide
Facilitators guideFacilitators guide
Facilitators guide
 
Art hmis tot training thika-photos
Art hmis tot training thika-photosArt hmis tot training thika-photos
Art hmis tot training thika-photos
 

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03.03 management of patients on antiretroviral drugs changi

  • 1. Module 3 Unit 3: Changing/stopping ART A Rational Approach to a Complicated Subject
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  • 12. A Rational Approach to the Management of Serious Side Effects Refer to “The National Clinical Manual for ARV Providers”
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  • 27. 2. Drug Interactions It is not possible to remember all the possible drugs interactions with ARV Drugs Refer to “The National ARV Guidelines”
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  • 35. 3. Treatment Failure Refer to “The National Clinical Manual for ARV Providers”
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Notas do Editor

  1. The extent of inhibition of mitochondrial DNA polymerase gamma is as follows d4T>Zalcitabine (ddC) > Didanosine ( ddI) > Lamivudine (3TC) > Zidovudine (ZDV) > Abacavir (ABC). Generally adverse events are less common in children compared to adults Hyperbilirubinemia, haematuria and nephrolithiasis with Indivanir is more pronounced in children There is high risk of hepatoxicity with ZDV in children below 5 years. Asymptomatic retinal pigmentation with ddI is more likely in children. Be on the look out for diarrhea with NFV and manage the same. The most common adverse events are graded ( see attached table) with suggestions of interventions at each level of grading.
  2. * In NNRTI containing regimens stopping all 3 drugs at once may allow for development of drug resistance. It is therefore recommended that the NRTI backbone should be continued for 2 weeks if possible to reduce the likelihood of NNRTI resistance developing. See Guidelines to ARV Treatment Minimizing Adverse Events Appropriate drug and regimen selection Dose titration Monitoring and reassuring for effects that are transient Appropriate timing of administration Pharmacological interventions Withdrawal of the offending drug(s)
  3. Grade 2 rash (maculopapular dry rash over >50%) body surface
  4. Grade 4 transaminiitis
  5. Grade 3