A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 5: Antiretroviral Therapy 5. 5 A doctor telephones you about a patient who has read about structured treatment interruption for patients who have failed therapy. You are told this patient has extensive experience with antiretroviral treatment for over 10 years, a CD4 cell count of 80-100/mm 3 , and a viral load that is back to baseline at 420,000 c/mL. Question: What would you recommend to the physician? a. Test resistance while receiving antiretroviral drugs and select the drugs based on the ART history and resistance tests b. Discontinue treatment, test the HIV strain at 12 weeks, and treat accordingly c. Continue therapy with same drugs d. Treat with lopinavir/ritonavir (LPV/r), Trizivir (AZT/3TC/ABC), tenofovir (TDF), and either efavirenz (EFV) or nevirapine (NVP) Answer: The experience with STI for virologic failure is that wild-type virus that is less resistant replaces the predominant strain after about 6-11 weeks, but the CD4 cell count drops rapidly during the period off treatment; after new treatment, the more completely resistant pre-STI strain returns. The largest experience indicates only about 10%-15% of these attempts have been judged successful. Therefore, STI for virologic failure has fallen into disfavor. Nevertheless, if you wanted to play long odds, the right time to do the testing is after there has been a sufficient interval for ingrowth of a new, more sensitive strain of HIV making option b the correct option. However, most would prefer option a with expert interpretation of the test results. 6. Question: Which of the following patients is the best candidate for genotype resistance testing? a. A previously untreated pregnant woman with HIV b. A chronically infected, previously untreated man with a partner who is currently taking triple therapy with poor control c. A woman who has failed her initial treatment with a viral load of 7,000 c/mL after 1 year on indinavir (IDV), ritonavir (RTV), lamivudine (3TC), and stavudine (d4T) d. A 40-year-old man with good virologic control, but a need to change therapy because of AZT-induced anemia Answer: Recommendations for the use of resistance testing are somewhat arbitrary, but the highest priority according to virtually all guidelines is for patients who have failed treatment for the purpose of identifying the next regimen; therefore, option c is the best answer. 38 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 6: Metabolic Complications of Antiretroviral Therapy Chapter 6: Metabolic Complications of Antiretroviral Therapy OVERVIEW LIPID ABNORMALITIES LIPODYSTROPHY LACTIC ACIDOSIS OTHER METABOLIC COMPLICATIONS David H. Spach, MD KEY POINTS SUGGESTED RESOURCES REFERENCES CASES OVERVIEW What is meant by metabolic complications of antiretroviral therapy (ART)? Metabolic complications refers to a group of adverse drug reactions that have been associated with long-term use of antiretroviral drugs, which include: See Glossary of • Lipid abnormalities Antiretroviral • Lipodystrophy Drugs on • Lactic acidosis page viii and the Pocket Guide • Hyperglycemia • Decreased bone mineral density Each adverse reaction is more commonly associated with a specific class of antiretroviral drugs, and the agents within the class that cause the reactions do so with variable frequencies. In most cases, the pathophysiologic mechanism of the changes is unknown. The classes of drugs associated with each major adverse reaction are listed in Table 6-1. What metabolic toxicities should you monitor for in patients taking ART? Recommendations for monitoring patients for ARTrelated metabolic complications, listed in Table 6-2, are discussed in detail in the sections below. 6 Adverse Reaction Table 6-1. Adverse Reactions of Classes of Antiretroviral Drugs Cause NRTIs* NNRTIs** PI*** Lactic acidosis ++ - - Lipid changes Elevated triglycerides - (+) ++ Elevated LDL cholesterol - + ++ Insulin resistance - - ++ Fat redistribution Fat atrophy + - - Fat accumulation - - ++ * NRTIs = Nucleoside and nucleotide reverse transcriptase inhibitors ** NNRTIs = Non-nucleoside reverse transcriptase inhibitors *** PIs = Protease inhibitors (+) = possibly causes adverse reaction + = sometimes causes adverse reaction ++ = frequently causes adverse reaction U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 39
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