The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

Chapter 27.26 picas Pharmacologic Interactionsof Clinical SignificanceJustina Edmunds-Ogbuokiri, PharmD, FASCPINTRODUCTION■ Patients receiving palliative care for HIV disease have the potential for numerous drug interactions,given the complex drug regimens used to treat both early as well as advancing HIVdisease. It is estimated that at any point, up to 50% of patients in palliative care may still berecipients of highly active antiretroviral therapy (HAART) which often comprises protease inhibitors(PIs) along with other antiretroviral agents, namely the nucleoside reverse transcriptaseinhibitors (NRTIs, or nukes) and the non-nucleoside reverse transcriptase inhibitors (NNRTIs,or non-nukes). All protease inhibitors as well as all currently available NNRTIs are metabolizedby the cytochrome P450 (CYP) isoenzymes and are therefore expected to be involved in a largenumber and variety of drug-drug interactions.As providers attempt to palliate advancing HIV disease, they may need to administer to patients—alongwith antiretroviral agents—medications for pain; insomnia; anorexia/weight loss;fatigue/weakness; GI disturbances including nausea, vomiting, diarrhea, dysphagia, odonophagiaand reflux esophagitis; dyspnea; pruritis; fever; anxiety/depression; confusion/dementia; and ahost of other symptoms. All of these medications may need to be administered in the presence ofother co-morbid conditions such as hepatitis; PI-associated complications such ashypertriglyceridemia, hyperglycemia, lipodystrophies and HIV-associated nephropathies; andthe opportunistic infections that are the hallmark of advanced HIV disease. It is therefore neithersurprising that drug-drug as well as drug-disease interactions become paramount considerationsas patients advance into palliative care, nor that optimizing therapy in these situationscan become exceedingly complex and overwhelming.Providers who care for people with HIV/AIDS must constantly keep abreast of new developmentsin antiretroviral drug treatment. The HIV/AIDS treatment guidelines are frequently updatedand the most current guidelines can be found at the AIDS info website, funded by theDepartment of Health and Human Services, at:www.aidsinfo.nih.gov/XXVIIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 549