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

4–24 | Clinical Manual for Management of the HIV-Infected Adult/2006
determine which of the medicines is the most likely
cause of the rash. In the case of the patient described
above, rash may be related to the following:
♦
♦
♦
♦
♦
♦
Mild ABC rash: Usually a self-limited reaction that
can be treated symptomatically
Moderate to severe ABC HSR: Resolution of
symptoms requires discontinuation of ABC, but
repeat challenge can be life threatening (see below
for more details)
Mild NVP rash: Usually a self-limited reaction that
can be treated symptomatically
Moderate to severe NVP rash accompanied by
hepatitis: Requires discontinuation of NVP
Mild TMP-SMX reaction: Either delayed or part of
an immune reconstitution reaction
Other reactions: can be caused by other medications,
contact dermatitis, folliculitis, immune reactivation
or reconstitution effect and other causes
If the clinician discontinues all of the suspect
medications and the rash resolves, the patient will be
relieved, but the clinician will not be able to determine
which medication caused the rash. In cases of mild
rash, it is reasonable to try to identify the offending
medication by discontinuing 1 medication at a time
(generally, a substitution should be made for the
discontinued ARV). This situation would require
careful clinical judgment or consultation with an
expert regarding the advantages or disadvantages of
discontinuing each of the suspect medications.
Abacavir hypersensitivity reactions
Abacavir hypersensitivity reactions are a common cause
of rash. The initial symptoms of possible ABC HSR
are not life threatening, and it is important to try to
distinguish true ABC HSR from isolated rash (without
other hypersensitivity symptoms), self-limited adverse
medication effects, or other illness (eg, influenza). This
is often best accomplished by asking a patient who
complains of mild gastrointestinal symptoms with
or without rash to continue taking all medications
while being monitored closely. Careful assessment
of symptoms for a few days should clarify whether
symptoms are lessening (indicating self-limited effects)
or worsening (suggesting of ABC HSR). The pattern of
symptom onset is also helpful. For patients with ABC
HSR, symptoms usually begin after 10 days of therapy
and worsen approximately 30-60 minutes after each
ABC dose administration. When ABC is discontinued
because of suspected HSR, patients should never be
rechallenged. Initial flulike symptoms are uncomfortable
for patients, but not life-threatening. If, however, ABC
is discontinued when HSR symptoms are present and is
then restarted, life-threatening HSRs may occur.
Clinicians should report ABC HSRs to the following
agencies:
♦
♦
Abacavir Hypersensitivity Reaction Registry at
Glaxo Wellcome at 1-800-270-0425
FDA MedWatch program by telephone at 800-
FDA-1088, via fax at 800-FDA-0178, via the
Internet at http://www.fda.gov/medwatch/report/hcp.
htm, or by mail at MedWatch HF-2, FDA, 5600
Fishers Lane, Rockville, MD 20857
Other Adverse Reactions
Patients may describe any number of adverse effects
after starting new medications. Although some
adverse effects are directly caused by the medications
themselves, some symptoms may occur simply in the
process of starting ARVs. The start of ARV therapy may
precipitate a significant psychological shift in a patient’s
perception of self, in living with HIV infection, and
in daily routine. In particular, patients who have kept
their HIV infection distant from their “everyday” lives
may notice significant internal changes as they take
medications every day, go to the pharmacy to pick up
medications, and make frequent visits to the clinic for
evaluation and laboratory work. Some patients become
depressed upon realizing that the severity of their
illness now requires them to be on treatment. These
psychological changes can cause significant symptoms
that should be assessed and managed similarly to the
pharmacologic adverse reactions.
These psychological effects can be considered “process”
effects from starting ARVs, rather than adverse effects
of the medications themselves. As with the selflimited
adverse effects of early ARV therapy, process
effects should become more tolerable over time as the
medication regimen becomes routine for the patient.
One of the most common process effects is fatigue.
Many patients hope that their ARV regimen will give
them increased energy and health, and they become
frustrated when they notice increasing fatigue after
starting the regimen. These patients must be evaluated
to rule out common adverse effects that contribute to
fatigue (eg, anemia, hepatitis, lactic acidosis). Equally
important, especially for patients beginning a new