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4–20 | Clinical Manual for Management of the HIV-Infected Adult/2006 References ♦ ♦ ♦ ♦ ♦ Liedtke MD, Lockhart SM, Rathbun RC. Anticonvulsant and antiretroviral interactions. Ann Pharmacother. 2004 Mar;38(3):482-9. Rainey PM. HIV drug interactions: the good, the bad, and the other. Ther Drug Monit. 2002 Feb;24(1):26-31. Piscitelli SC, Gallicano KD. Interactions among drugs for HIV and opportunistic infections. N Engl J Med. 2001 Mar 29;344(13):984-96. Sheehan NL, Kelly DV, Tseng AL, et al. Evaluation of HIV drug interaction web sites. Ann Pharmacother. 2003 Nov;37(11):1577-86. U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV- 1-Infected Adults and Adolescents. October 10, 2006. Available online at aidsinfo.nih.gov/Guidelines/ GuidelineDetail.aspx?GuidelineID=7. Accessed July 7, 2007. Resources ♦ ♦ ♦ ♦ HIV InSite Database of Antiretroviral Drug Interactions: http://hivinsite.ucsf.edu/arvdb?page=ar-00-02 Toronto General Hospital Drug Interaction Tables: http://tthhivclinic.com/interact_tables.html Discover Drug Interaction Checker: http://health.discovery.com/encyclopedias/checker/ checker.jsp Check my Meds on AIDSMeds.com: http://aidsmeds.com/cmm/DrugsNewContent.asp
Adverse Reactions to HIV Medications Background Clinicians and patients face many challenges associated with antiretroviral (ARV) therapy. These include decisions about when to start therapy, what regimen to start with, when to change medications, and how to switch if a regimen is failing. Although clinical research should guide the selection of ARV regimens, it is important to remember that the best regimen for any individual patient is the regimen he or she is willing and able to take. No regimen, no matter how potent, will be effective if the patient does not take it properly. Adherence to ARV therapy is one of the most important predictors of treatment efficacy. Although many factors may interfere with adherence to ARV therapy, adverse reactions to the medications are among the most important. In one trial, patients with adverse events were 13 times less likely than those without adverse events to have 95-100% adherence. Monitoring and managing adverse reactions to ARVs are crucial to establishing a successful HIV regimen. Although adverse reactions are common and often predictable, their management must be individualized. Several factors will affect the management of adverse reactions, including comorbid conditions, the patient’s other current medications, the availability of alternative regimens, and the patient’s history of medication intolerance. In addition, the patient’s report of severity can be inconsistent with the clinical interpretation (ie, some patients may overemphasize symptoms, whereas others underemphasize symptoms), and this must be considered when determining the management of adverse reactions. This chapter reviews some of the most common adverse effects noted as patients start an ARV regimen and suggests strategies for the management of adverse effects. It is not intended as a comprehensive guide to adverse effects. For detailed information regarding assessment of symptoms, see the complaint-specific chapters found in Section 5 of this manual. For information on common adverse reactions to ARV agents and to medications used to prevent and treat opportunistic infections, see Section 10 of this manual. Consultation with an HIV expert also can help in determining the best management when symptoms may have multiple and overlapping causes. Finally, in each Section 4—Complications of Antiretroviral Therapy | 4–21 case of suspected medication adverse effects, the patient should be evaluated for other possible causes of his or her symptoms. S: Subjective A patient presents 2 weeks after starting her new ARV regimen complaining of fatigue, nausea, and rash. Her current ARV medications include a combination of zidovudine (ZDV), lamivudine (3TC), and abacavir (ABC) (ie, Trizivir)—and nevirapine (NVP). She has continued her prophylactic medications, which include trimethoprim-sulfamethoxazole (TMP-SMX) and fluconazole. Although she reports that she had not missed any doses of her medications and she likes the low pill burden of this regimen, she does not want to continue because she has been feeling so sick that she cannot adequately care for her children. She is asking to stop her ARV therapy because of “too many side effects.” The patient should be evaluated in the clinic for her complaints about adverse effects. O: Objective The following are suggestions for this evaluation; they are not intended to be a complete review of the workup and management of each symptom or objective finding. For more detailed information, refer to the complaintspecific chapters of this manual, as noted above. ♦ ♦ Vital signs: Fever may indicate a hypersensitivity reaction (HSR), acute hepatitis, or immune reconstitution syndrome related to starting ARV medications. See the chapter Fever for a more complete discussion about fever workup and considerations. Tachycardia or hypotension may suggest anemia, HSR, dehydration, or another illness. Physical examination: Pay special attention to the skin (rash, pallor), mucous membranes, and liver (enlargement or tenderness). Positive physical examination findings should be evaluated for severity and extent of involvement.
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Table of Contents Clinical Manual f
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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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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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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Neurologic Symptoms Background The
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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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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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