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4–22 | Clinical Manual for Management of the HIV-Infected Adult/2006 ♦ ♦ Laboratory tests: Complete blood count is important when monitoring drugs that may cause bone marrow toxicity (eg, anemia, neutropenia). Perform a complete metabolic panel including electrolytes and liver function tests (LFTs). If the history suggests pancreatitis, evaluate amylase or lipase. Other studies: Perform as indicated by symptoms and examination (eg, chest x-ray if respiratory symptoms are present). A: Assessment Step 1: Clarify reports of adverse reactions by requesting the following information for each symptom the patient describes: ♦ ♦ ♦ Characterize the symptoms by asking about severity, onset, and frequency. It is also helpful to have the patient describe whether the symptom(s) have been improving or worsening over time. Ask whether the patient has tried any remedies to alleviate the symptom(s) and whether they were helpful. Explore how the patient is currently taking the regimen. Open-ended questions such as: "What are your current medications?" "How often do you take them?" "How many pills of each medicine do you take?" and "Do you take your medicines with or without food?" can be helpful in determining whether the patient has been taking medications correctly. Incorrect administration of medications (eg, taking higher dosages than recommended) can lead to adverse effects and is often overlooked by providers. Step 2: Assess the severity of the reaction against the need to continue the current regimen. An understanding about the relative availability of alternative ARV regimens is important in this assessment ♦ Most adverse effects are self-limited and mild-tomoderate in severity. With supportive care, patients often are able to continue their current medications. This is particularly true for gastrointestinal symptoms (eg, nausea, vomiting, bloating). Supportive care for gastrointestinal adverse effects includes reminding the patient to take medications with food (if appropriate), suggesting the use of ginger-containing beverages or foods to relieve symptoms (see “Nausea,” below), and prescribing antiemetics if needed. Other symptoms that can be ♦ ♦ ♦ monitored carefully with supportive care include: fatigue, malaise, mild rashes, abdominal pain, and bloating. More severe reactions often require discontinuation of the offending medication. These include fever, LFT abnormalities, or severe systemic symptoms. Determining which of the medications is causing the reaction is often challenging, because patients are commonly taking several medications with overlapping toxicities. The threshold for stopping a medication depends in part on the availability of alternative agents for any given patient. Some patients have limited alternatives because their virus is resistant to other ARV agents (eg, patients on salvage ARV regimens). For other patients, alternatives are limited by past adverse effects. For patients who develop significant adverse effects when starting their first ARV regimen, substituting alternative ARV medications that are better tolerated should be considered as early as possible during therapy to avoid nonadherence due to adverse effects. For these situations, single-drug substitutions often improve tolerance and achieve long-term viral suppression. Some patients may refuse to attempt supportive care and refuse to continue treatment. In these situations, it may be best to discontinue all ARV medications and return to an adherence-readiness assessment (see chapter Adherence) to determine when to restart medications and what medications to restart (see chapter Antiretroviral Therapy). Clarified Subjective and Objective Information For the patient who reported nausea, fatigue, and rash 2 weeks after starting ZDV/3TC/ABC (Trizivir) and NVP (see above), additional history, physical examination, and laboratory work yielded the following information: ♦ ♦ Nausea: This was present since she started ARVs 2 weeks ago. She has had difficulty taking medications with food, because of nausea. No actual vomiting or other abdominal pain has occurred. She has not tried any remedies. The nausea is not worsening and perhaps has improved slightly over the past few days. Fatigue: This was present since she started ARVs 2 weeks ago. She is able to exercise and perform normal daily activities.
♦ ♦ ♦ ♦ ♦ Vital signs: Normal; no fever or signs of hemodynamic changes. Skin: Skin and conjunctival pallor is noted, along with mild to moderate maculopapular rash on the trunk, back, and extremities. These are associated with slight itching, but no pain. No mucous membrane involvement is noted. The rash has been present for 4 days, with slight improvement over the past day. Abdomen: Nontender, with normal liver size. Complete Blood Count: Normal, except for a slight increase in mean corpuscular volume (MCV), probably from ZDV therapy and not indicating macrocytic anemia. LFTs: Normal. Availability of Alternative Regimens A clarified ARV history yielded the following information. The patient took ZDV alone for 3 months a few years ago, during 1 of her pregnancies, and recalls similar feelings of nausea and fatigue that caused her distress at the time. She was able to continue ZDV through the end of her pregnancy. Otherwise, the patient is ARV naive and has many treatment options. Assessment and Conclusion The patient’s symptoms are mild and are most likely related to starting ARV therapy. Thus, no additional workup is needed at this time. Careful monitoring is important because, if symptoms do not improve over the next few days, the patient should have a more extensive workup for other possible causes of the various symptoms. If other causes of her symptoms are ruled out and she is unable to tolerate supportive care, alternative ARV medications (eg, didanosine, tenofovir, protease inhibitors) can be substituted for medications in her current regimen. Given her ARV history, substitutions are likely to be effective. P: Plan Following is a suggested treatment plan for the mild adverse effects exhibited by the patient described above: Fatigue Fatigue is a common adverse effect among patients who are starting ARV therapy. It is usually self-limited, and, with reassurance that symptoms should improve Section 4—Complications of Antiretroviral Therapy | 4–23 over a few weeks, most patients are able to continue their regimens without any changes. If fatigue does not resolve within the first weeks of treatment, it is important to rule out other causes of fatigue, including depression. For ZDV-containing regimens, practitioners should also rule out ZDV-induced anemia, especially when patients are also taking other medications that can cause bone marrow toxicity (eg, TMP-SMX). Some patients experience fatigue from ZDV even without anemia. If fatigue persists for several weeks or becomes debilitating and other causes are ruled out, consider replacing ZDV in this regimen. (See also chapter Fatigue.) Nausea Nausea is another common adverse effect described by patients starting a new ARV regimen. Like fatigue, it is usually self-limited, and patients without other systemic symptoms, acute hepatitis, or pancreatitis usually can continue their regimens. Supportive care is often helpful, however, in allowing patients to continue their ARVs. For example, patients should take their medications with food. Small, frequent snacks may be helpful for patients with significant nausea that prevents substantial meals. Clinical trials have suggested that ginger extract may relieve nausea symptoms. Patients can take ginger in a variety of forms, including ginger ale, tea, cookies, and candies. Among the medications that the current patient is taking, ZDV is the most likely culprit to cause persistent nausea. If nausea symptoms persist for several weeks despite taking medications with food, using ginger, or taking other antiemetics, and if other underlying causes are ruled out, consider replacing ZDV in this regimen. (See also chapter Nausea and Vomiting.) Rash Rash is a common adverse effect of certain ARVs and many other medications. It may present with a wide range of severity: ♦ ♦ ♦ Mild rash occurs with no other related symptoms and resolves over days or weeks. Moderate rash may be accompanied by systemic symptoms (eg, fever, LFT abnormalities, myalgias). Life-threatening rashes (eg, Stevens-Johnson syndrome) associated with pain, mucous membrane involvement, fever, LFT changes, and myalgias. If a patient is taking 2 or more medications that have rash as a possible adverse effect, it may be difficult to
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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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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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Reducing Maternal-Infant HIV Transm
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Page 175 and 176: Recreational Drugs and Antiretrovir
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Page 181 and 182: Immune Reconstitution Syndrome Back
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Page 185 and 186: ♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Page 210 and 211: Fever Background Although fever may
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Page 214 and 215: Lymphadenopathy Background Lymphade
Page 216: 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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