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

More documents

Recommendations

Info

pregnancy. Ribavirin is teratogenic, and both women and men must use contraception consistently during treatment with ribavirin and for 6 months after treatment. IFN may cause fetal growth abnormalities, and is abortifacient in animals. Treatment of acute HCV Treatment of acute HCV is associated with a much higher response rate than treatment during the chronic phase. However, delaying therapy for 12 weeks to ascertain whether spontaneous clearance will occur does not affect treatment response rates. Treatment with PEG-IFN monotherapy has been associated with viral eradication in >90% of patients. Treatment for 24 weeks appears to be sufficient to clear HCV. Timing of HCV treatment and HIV treatment The decision of whether and when to treat HCV among people infected with HIV must be determined individually. When coinfected patients require treatment for both infections, some experts begin with HIV treatment in hope that by improving CD4 counts, they may enhance the response to HCV therapy, even though CD4 cell counts by themselves are not firmly associated with an increased likelihood of a sustained virologic response. Other experts choose to treat HCV before initiating ARV therapy (ART) in those with high CD4 counts and low HIV viral loads to simplify treatment and improve the tolerability of ART. Consult with an HCV treatment expert to determine the appropriateness and timing of HCV treatment. Some patients with HCV will experience worsening of hepatic function during ART, and liver function tests should be monitored closely. Some ARV medications are hepatotoxic and should be avoided or used cautiously; these include nevirapine, tipranavir, and high-dose ritonavir. Numerous other medications (eg, fluconazole and isoniazid) are hepatotoxic and can pose problems for people with impaired liver function. Other Care Issues Acute hepatitis A or hepatitis B infection in persons with chronic HCV can cause fulminant liver disease. All patients with HCV infection should be tested for immunity to hepatitis A and hepatitis B; patients who are not immune should be vaccinated. Persons with HCV infection should be counseled to avoid exposure to hepatotoxins, including alcohol and hepatotoxic medications (eg, acetaminophen in large doses, fluconazole, and isoniazid). All patients should Section 6—Disease-Specific Treatment | 6–43 be counseled to reduce the risk of transmitting HCV to others. As appropriate, patients should be advised to adopt “safer sex” approaches, avoid blood exposures (eg, from sharing razors or tattoo equipment), practice safe drug injection techniques, and avoid pregnancy. Patient Education ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Most patients with HCV will remain asymptomatic for several years. However, ongoing injury to the liver occurs during this time and can culminate in liver failure. Patients can slow the damage by avoiding alcohol and any medications (including over-the-counter drugs and recreational drugs) that may damage the liver. Patients should contact their pharmacist or health care provider if they have questions about a specific medication or supplement. As with HIV, patients must avoid passing HCV to others. Instruct patients not to share toothbrushes, dental appliances, razors, sex toys, tattoo equipment, injection equipment, or personal care items that may have blood on them. Emphasize the importance of safer sex to protect themselves and their partner(s). Tell patients to discuss HCV with their sex partner(s), and suggest that partner(s) get tested for HCV. Pregnant women have a high risk of transmitting HIV or HCV infection to the baby because each virus makes it easier to transmit the other. Women who are pregnant or considering pregnancy should talk with a specialist in HIV and HCV to discuss ways to decrease the infection risk for the baby. HCV medications (ribavirin and interferon) should not be given during pregnancy. Both men and women who are taking ribavirin should use contraception consistently during ribavirin therapy and for 6 months after completion of treatment. If children were born after women were infected with HCV, consider having them tested as well. Even though their risk is low, they should be screened for HCV. Certain ARV drugs are more likely to cause problems with the liver because of HCV. Advise patients that if they start an ARV regimen, their liver function tests should be watched carefully to be sure that the body is able to process the medicines. Patients who not been vaccinated against hepatitis A need to receive 2 vaccinations 6 months apart.
6–44 | Clinical Manual for Management of the HIV-Infected Adult/2006 ♦ ♦ ♦ ♦ ♦ Hepatitis A can cause severe illness damage, or even death, in people with HCV. Patients who have not been vaccinated against hepatitis B should complete the vaccine series, which requires 3 shots. If patients have been vaccinated in the past, they should have the anti-HBV titer checked to make sure that they are still protected. Hepatitis B can worsen liver function greatly if it is acquired in addition to HCV. Patients who are not immune to hepatitis B should use safer sex (latex barriers) to avoid exposure. Patients who use injection drugs should not share needles or injection equipment. Patients who use injection drugs should consider entering a treatment program. Quitting drug use will reduce the strain on the liver, protect patients from other blood-borne illnesses that can affect the liver, and help prevent transmission of HCV to others. Patients who are not ready to stop injection drug use should let their providers know so that they can try to help find a source for clean, single-use needles. Hepatitis C is not spread by coughing, sneezing, hugging, sharing food and water, or other casual contact. The HCV treatments interferon alfa and ribavirin can cause flulike symptoms, body aches, fevers, anemia, neuropathy, and depression. Most of these adverse effects are treatable with medications. Patients should contact their medical provider right away if they experience depression. Antidepressant medications that can help relieve depression, but the medications take a couple of weeks to become effective. References ♦ ♦ Carrat F, Bani-Sadr F, Pol S, et al. Pegylated interferon alfa-2b vs standard interferon alfa-2b, plus ribavirin, for chronic hepatitis C in HIV-infected patients: a randomized controlled trial. JAMA. 2004 Dec 15;292(23):2839-48. Centers for Disease Control and Prevention, National Institutes of Health, HIV Medicine Association/Infectious Diseases Society of America. Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents. MMWR Recomm Rep. 2004 Dec 17; 53(RR15);1-112. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail. aspx?GuidelineID=14. Accessed May 19, 2006. ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Chung RT, Andersen J, Volberding P, et al. Peginterferon Alfa-2a plus ribavirin versus interferon alfa-2a plus ribavirin for chronic hepatitis C in HIV-coinfected persons. N Engl J Med. 2004 Jul 29;351(5):451-9. Fried MW. Advances in therapy for chronic hepatitis C. Clin Liver Dis. 2001 Nov;5(4):1009-23. Gonzalez SA, Talal AH. Hepatitis C virus in human immunodeficiency virus-infected individuals: an emerging comorbidity with significant implications. Semin Liver Dis. 2003 May;23(2):149-66. Heller B, Rehermann T. Acute hepatitis C: a multifaceted disease. Semin Liver Dis. 2005 Feb;25(1):7-17. Jaeckel E, Cornberg M, Wedemeyer H, et al. Treatment of acute hepatitis C with interferon alfa-2b. N Engl J Med. 2001 Nov 15;345(20):1452-7. National Institutes of Health. NIH Consensus Development Conference Statement: Management of Hepatitis C 2002. Accessed February 7, 2006. Sulkowski MS, Thomas DL, Chaisson RE, et al. Hepatotoxicity associated with antiretroviral therapy in adults infected with human immunodeficiency virus and the role of hepatitis C or B virus infection. JAMA. 2000 Jan 5;283(1):74-80. Talal AH, Shata MT, Markatou M, et al. Virus dynamics and immune responses during treatment in patients coinfected with hepatitis C and HIV. J Acquir Immune Defic Syndr. 2004 Feb 1;35(2):103-13. Torriani FJ, Rodriguez Torres M, Rockstroh JK, et al. Peginterferon alfa-2a plus ribavirin for chronic hepatitis C virus infection in HIV-infected patients. N Engl J Med. 2004 Jul 29;351(5):438-50. U.S. Public Health Service, Infectious Diseases Society of America. 2002 Guidelines for preventing opportunistic infections among HIV-infected persons. MMWR Recomm Rep. 2002 Jun 14;51(RR08);1- 46. Available online at aidsinfo.nih.gov/Guidelines/. Accessed May 19, 2006. Zeremski M, Talal AH. Noninvasive markers of hepatic fibrosis: are they ready for prime time in the management of HIV/HCV co-infected patients? J Hepatol. 2005 Jul;43(1):2-5.
Page 1 and 2:
Clinical Manual for Management of t
Page 3 and 4:
Table of Contents Clinical Manual f
Page 5 and 6:
Clinical Manual for Management of t
Page 7 and 8:
Preface—About this Manual | Clini
Page 9:
Previous Editions Atlanta Contribut
Page 12 and 13:
♦ ♦ ♦ ♦ ♦ | Clinical Manu
Page 14 and 15:
1-2 | Clinical Manual for Managemen
Page 16 and 17:
Page 18 and 19:
Page 20 and 21:
Page 23 and 24:
Initial Physical Examination Backgr
Page 25 and 26:
Genitals/Rectum • Inspect the gen
Page 27 and 28:
Initial and Interim Laboratory and
Page 29 and 30:
Section 1—Testing and Assessment
Page 31:
Patient Education ♦ ♦ ♦ ♦ D
Page 34 and 35:
1-22 | Clinical Manual for Manageme
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 46 and 47:
Page 48 and 49:
Page 51 and 52:
Section 2—Health Maintenance and
Page 53:
References ♦ ♦ ♦ ♦ ♦ ♦
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 67 and 68:
Occupational Postexposure Prophylax
Page 69 and 70:
P: Plan Laboratory Testing Provide
Page 71 and 72:
For hepatitis C, no recommended pro
Page 73 and 74:
Page 75 and 76:
as hepatitis C or another sexually
Page 77 and 78:
for treatment is appropriate, and b
Page 79 and 80:
Page 81 and 82:
contact with the patient. Patients
Page 83 and 84:
tablet daily of trimethoprim-sulfam
Page 85 and 86:
Opportunistic Infection Prophylaxis
Page 87 and 88:
Discontinuing Primary Prophylaxis P
Page 89 and 90:
Latent Tuberculosis Background Late
Page 91 and 92:
INH may cause liver toxicity and it
Page 93:
Patient Education ♦ ♦ ♦ ♦
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 117 and 118:
Reducing Maternal-Infant HIV Transm
Page 119 and 120:
Some states require written informe
Page 121 and 122:
contraindicated during pregnancy be
Page 123 and 124:
Section 3—Antiretroviral Therapy
Page 125 and 126:
Nelfinavir (Viracept) Adequate drug
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Patient Education ♦ ♦ ♦ ♦
Page 133:
♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
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
Page 171 and 172:
♦ ♦ ♦ ♦ ♦ Vital signs: No
Page 173 and 174:
egimen, symptoms of fatigue could i
Page 175 and 176:
Recreational Drugs and Antiretrovir
Page 177 and 178:
Section 4—Complications of Antire
Page 179 and 180:
LSD, Mescaline, Psilocin, and Methy
Page 181 and 182:
Immune Reconstitution Syndrome Back
Page 183 and 184:
A: Assessment In the appropriate cl
Page 185 and 186:
♦ ♦ ♦ ♦ ♦ Navas E, Martin
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 202 and 203:
Eye Problems Background The immunos
Page 204:
of
Page 207 and 208:
Page 210 and 211:
Fever Background Although fever may
Page 212 and 213:
Headache Background Headache may ha
Page 214 and 215:
Lymphadenopathy Background Lymphade
Page 216:
Treatment Treatment will depend on
Page 219 and 220:
Page 222 and 223:
Neurologic Symptoms Background The
Page 224 and 225:
♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
Page 226 and 227: Pulmonary Symptoms Background Short
Page 228: Treatment Once the diagnosis is mad
Page 231 and 232: 5-46 | Clinical Manual for Manageme
Page 235 and 236: 6-2 | Clinical Manual for Managemen
Page 238 and 239: Candidiasis, Oral and Esophageal Ba
Page 240: Maintenance therapy Use caution whe
Page 246 and 247: Cervical Dysplasia Background Cervi
Page 248: Patient Education ♦ ♦ ♦ ♦ P
Page 254 and 255: Cryptosporidiosis Background Crypto
Page 256: Patient Education ♦ ♦ ♦ ♦
Page 266 and 267: Gonorrhea and Chlamydia Background
Page 268 and 269: Treatment of Gonorrhea Treatment op
Page 270 and 271: Hepatitis B Infection Background He
Page 272 and 273: ♦ ♦ ♦ ♦ ♦ Some patients t
Page 274 and 275: Hepatitis C Infection Background He
Page 278 and 279: Herpes Simplex, Mucocutaneous Backg
Page 280: References ♦ ♦ ♦ ♦ ♦ Cent
Page 288 and 289: Kaposi Sarcoma Background Kaposi sa
Page 290 and 291: Treatment Treatment of KS is not co
Page 292 and 293: Molluscum Contagiosum Background Mo
Page 294 and 295: Mycobacterium avium Complex Backgro
Page 296 and 297: Table 1. Interactions between Rifab
Page 298 and 299: Mycobacterium tuberculosis: Treatme
Page 300 and 301: P: Plan Diagnostic Evaluation Durin
Page 302 and 303: Table 1. Regimens for Treatment of
Page 304 and 305: Rifabutin may be substituted for ri
Page 306: Patient Education ♦ ♦ ♦ ♦
Page 314 and 315: Non-Hodgkin Lymphoma Background Non
Page 316: Patient Education ♦ ♦ ♦ ♦ S
Page 327 and 328:
Page 329 and 330:
Page 331 and 332:
Page 333 and 334:
6-100| Clinical Manual for Manageme
Page 335 and 336:
6-102| Clinical Manual for Manageme
Page 338 and 339:
Toxoplasmosis Background Toxoplasma
Page 340 and 341:
♦ Atovaquone 1,500 mg orally twic
Page 342 and 343:
Linear Gingival Erythema Background
Page 344 and 345:
Background Necrotizing ulcerating p
Page 346 and 347:
Oral Health Background Examination
Page 348 and 349:
Maxillary Tori; Mandibular Tori S:
Page 350 and 351:
Periodontal Disease Background The
Page 352 and 353:
Oral Hairy Leukoplakia Background O
Page 354 and 355:
Oral Ulceration Background Oral ulc
Page 356 and 357:
Oral Warts Background Oral warts ar
Page 358 and 359:
Page 360 and 361:
Page 362 and 363:
Page 364 and 365:
Page 366 and 367:
Page 369 and 370:
Anxiety Disorders Background Anxiet
Page 371:
Patient Education ♦ ♦ Behaviora
Page 374 and 375:
Page 376 and 377:
Page 378 and 379:
Page 381 and 382:
Insomnia Background Insomnia is a c
Page 383 and 384:
Suicidal Ideation Background Transi
Page 385 and 386:
Section 8—Neuropsychiatric Disord
Page 387 and 388:
P: Plan ♦ ♦ ♦ ♦ ♦ Check t
Page 389 and 390:
Correctional Settings Background Ca
Page 391 and 392:
Adherence Adherence is one of the m
Page 393:
Karnofsky Performance Scale Backgro
Page 396 and 397:
Page 398 and 399:
Page 400:
show all

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

Create successful ePaper yourself

Delete template?

Save as template?