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

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 27: Pharmacologic Interactions of Clinical SignificanceTable 27-5:Results of Drug Interaction Studies in the Presence of Ritonavir,the Most Potent CYP450-Modifying Protease InhibitorCo-administered DrugResultsTerfenadine (Seldane)Bupropion (Wellbutrin)Increased risk of cardiotoxicity.Increased risk of bupropion toxicity includingseizures. Avoid concomitant use.Clozapine (Clozaril)Increased risk of clozapine toxicity includingagranulocytosis.ECG changes and seizures.Desipramine (Norpramin) 145% increase in desipramine AUC, no dosageadjustment needed, monitor more closely.BenzodiazepinesIncreased risk of prolonged sedation and respiratorydepression.Zolpidem (Ambien)Increased risk of prolonged sedation and respiratorydepression.Ethinyl estradiol40% decrease in ethinyl estradiol AUC, no change(oral contraceptives) adjustment is needed, alternative and additionalcontraception advised.Meperidine (Demerol)Increased risk of meperidine toxicity, including CNSside effects, seizures and cardiac arrhythmias.Nevirapine (Viramune)Cisapride (Propulsid)Rifabutin (Mycobutin)Didanosine (Videx)Piroxicam (Feldene)Saquinavir (Fortovase, Invirase)Sulfamethoxazole (Bactrim)Clarithromycin (Biaxin)AstemizoleEfficacy of ritonavir may be decreased.Increased risk of torsades des pointes cardiotoxicity.Drug has recently been removed from the marketbecause of this.Ritonavir increases the risk of rifabutin-inducedhematological toxicity by decreasing its metabolism.Rifabutin, a potent inducer of CYP enzymes, hastensmetabolism of ritonavir and by so doing decreases itsefficacy.Ritonavir causes a 13% decrease in the AUC ofdidanosine, however no dosage adjustments are needed.Increased risk of piroxicam toxicity.Twenty- to thirty-fold increase in saquinavir AUC. Usedto boost levels of saquinavir, reduce dosing frequencyand reduce pill burden.20% decrease in sulfamethoxazole (Bactrim) AUC maylead to a decrease in allergic reactions especially rashand hematological side effects. Patient must maintaingood fluid intake and be monitored more closely.77% increase in clarithromycin AUC. No dosagereduction is needed for patients with normal renalfunction. For patients with clearance 30-60ml/min,decrease dose by 50%; for patients with clearance
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 27: Pharmacologic Interactions of Clinical SignificanceTable 27-6a: Medications Known to Prolong QTC IntervalAntiarrhythmics26 picasAntibiotics and Antiviral AgentsPsychotropicsQuinidine, procainamide, disopyramide, amiodarone,sotalol, bretylium, dofetilide, bepridilErythromycin, quinine, chloroquine, moxifloxacin,sparfloxacin, gatifloxacin, and amantadineTricyclic antidepressants, citalopram, chloral hydrate,lithium, pimozide, thioridazine, droperidol,ziprasidoneTable 27-6b: Clinical Monitoring for Drugs That May Prolong QTCTips for Counseling Patients• Immediately report tachycardia, lightheadedness, palpitations, vomiting or diarrhea.• Avoid use of street drugs, substances of abuse, or excessive use of alcohol. Notify psychiatristbefore taking any prescription or over-the-counter drugs.• Baseline and periodic screening should be done for serum potassium (K+), serum magnesium(Mg+), and electrocardiogram (ECG).Interactions between HAART Drugs andOther Drugs Used by Patients with Advancing HIV DiseaseClinicians should become familiar with these interactions of clinical significance betweenantiretroviral drugs and ancillary drugs needed to manage the many complications of advancingHIV disease. Providers should avoid drug combinations likely to result in potentially seriousinteractions. Table 27-5 provides a detailed list of the drug interaction studies in the presence ofritonavir, the most potent CYP-modifying protease inhibitor, while Tables 27-6a and 27-6b offerclinical monitoring highlights and counseling tips for patients using drugs that may prolong theQTC interval.Drug Interactions Involving Amprenavir (Agenerase) and Vitamin EOne capsule of amprenavir (Agenerase) contains 109 international units (IUs) of vitamin E.The daily dose of eight capsules of amprenavir, taken twice daily which adds up to 1,200 IUs, hasbeen established as the minimum toxic dose (MTD); this is the smallest dose that has beenfound to be harmful when taken over a period of time. The manufacturer, Glaxo-Wellcome, notesin the package insert that people taking amprenavir should not take any extra vitamin E. Highdoses of vitamin E can create problems because vitamin E is a blood thinner and so can causeproblems with other blood thinners such as warfarin (Coumadin), vitamin K or clotting factors.One woman on long-term warfarin experienced intracranial bleeding less than a week afterstarting amprenavir. People taking low-dose aspirin daily to prevent heart attacks as well aspeople on herbal blood thinners like ginger, garlic, feverfew, ginseng and ginkgo biloba shouldalso be careful with the extra vitamin E in amprenavir. Symptoms of vitamin E toxicity (which isordinarily rare) include spontaneous nosebleeds, cuts that will not stop bleeding and bruisesacquired easily. 9XXVIIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 561
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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A Clinical Guide to Supportive and
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Chapter 6.26 picasPulmonary Symptom
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Chapter 8.26 picasOral ProblemsDavi
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 25.26 picas Prevention of S
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