Clinical Manual for Management of the HIV-Infected ... - myCME.com

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.
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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.