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4–6 | Clinical Manual for Management of the HIV-Infected Adult/2006 ♦ ♦ ♦ ♦ Assess for CHD or CHD equivalents. ♦ ♦ CHD includes a history of myocardial infarction, unstable angina, stable angina, CHD procedures, or evidence of clinically significant myocardial ischemia. CHD equivalents include diabetes, peripheral vascular disease, carotid artery disease, abdominal aortic aneurysm, transient ischemic attacks, or 2 or more CHD risk factors with a 10-year risk of CHD >20% (see “Calculations to Estimate the 10-Year Risk of Cardiac Events for Men and Women”, below, or the online risk calculator at http://hin.nhlbi.nih.gov/atpiii/ calculator.asp?usertype=prof). Assess CHD risks. Major risk factors include hypertension, diabetes, smoking, low HDL, age, and family history of CHD. Assess for causes of secondary dyslipidemias, including diabetes, hypothyroidism, obstructive liver diseases, chronic renal failure, and medications such as corticosteroids or progestins. Screen for other factors that contribute to hyperlipidemia, including obesity, chronic liver diseases, alcohol abuse, high-fat or highcarbohydrate diet, and prothrombotic or proinflammatory states. Screen for health behaviors that increase CHD risk, including smoking, high-fat diet, sedentary lifestyle, and use of recreational drugs such as cocaine or methamphetamine. Review the patient’s family history for premature CHD, obesity, diabetes, and lipid abnormalities. Review the patient’s medications, with special attention to ARVs known to increase LDL or TG levels (particularly ritonavir and ritonavir-boosted PIs) or decrease HDL. O: Objective Table 1. Low-Density Lipoprotein Cholesterol Goals and Thresholds for Treatment* Risk Category Initiate Therapeutic Lifestyle Changes Lower risk: No CHD or CHD equivalents and 2 risk factors, with 10-year estimated risk 2 risk factors and 10year estimated risk 10-20% LDL >160 mg/dL (>4.1 mmol/L) LDL >130 mg/dL (>3.4 mmol/L) LDL >130 mg/dL (>3.4 mmol/L) High risk: CHD or CHD equivalent LDL >100 mg/dL (>2.6 mmol/L) ♦ ♦ ♦ Check vital signs, weight, and height. Calculate body mass index (BMI). (See chapter Initial Physical Examination for information on BMI.) Perform a focused physical examination with particular attention to signs of hyperlipidemia, such as xanthelasma, and to the cardiovascular system. Consider Drug Therapy LDL Goal* >190 mg/dL (>4.9 mmol/L) (at 160-189 mg/dL, LDL drug therapy is optional) >160 mg/dL (>4.1 mmol/L) >130 mg/dL (>3.4 mmol/L) >100 mg/dL (>2.6 mmol/L)
Table 2. Classification of Triglyceride Levels Risk Category Triglyceride Measurement Normal triglycerides 500 mg/dL Hypertriglyceridemia is an independent risk factor for CHD. In addition, severe hypertriglyceridemia (eg, TG >1,000 mg/dL) increases the risk for pancreatitis. Patients with marked TG elevations should be treated to reduce this risk. A: Assessment Determine whether intervention is appropriate based on the patient’s lipid values and identified CHD risks, as indicated in Tables 1 and 2. Aside from LDL, the following major CHD risk factors are listed by the NCEP as requiring intensive lipid management. ♦ ♦ ♦ ♦ Cigarette smoking Hypertension (systolic blood pressure >140 mm Hg or taking antihypertensive medication) HDL 60 mg/dL, subtract 1 risk factor) Patient age >45 for men, or >55 for women Family history of premature CHD in first-degree relatives aged
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Clinical Manual for Management of t
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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1-22 | Clinical Manual for Manageme
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Page 104 and 105: 3-8 | Clinical Manual for Managemen
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Page 117 and 118: Reducing Maternal-Infant HIV Transm
Page 119 and 120: Some states require written informe
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Page 123 and 124: Section 3—Antiretroviral Therapy
Page 125 and 126: Nelfinavir (Viracept) Adequate drug
Page 131 and 132: Patient Education ♦ ♦ ♦ ♦
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Page 165 and 166: Section 4—Complications of Antire
Page 167 and 168: ♦ ♦ ♦ Toronto General Hospita
Page 169 and 170: Adverse Reactions to HIV Medication
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Page 175 and 176: Recreational Drugs and Antiretrovir
Page 177 and 178: Section 4—Complications of Antire
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Page 181 and 182: Immune Reconstitution Syndrome Back
Page 183 and 184: A: Assessment In the appropriate cl
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Page 202 and 203: Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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♦ ♦ ♦ ♦ ♦ Some patients t
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Non-Hodgkin Lymphoma Background Non
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Patient Education ♦ ♦ ♦ ♦ S
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Toxoplasmosis Background Toxoplasma
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♦ Atovaquone 1,500 mg orally twic
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Linear Gingival Erythema Background
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Background Necrotizing ulcerating p
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Oral Health Background Examination
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Maxillary Tori; Mandibular Tori S:
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Periodontal Disease Background The
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Oral Hairy Leukoplakia Background O
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Oral Ulceration Background Oral ulc
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Oral Warts Background Oral warts ar
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Anxiety Disorders Background Anxiet
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Patient Education ♦ ♦ Behaviora
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Insomnia Background Insomnia is a c
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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