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Table 1. Interactions between Rifabutin and Antiretroviral Medications: Contraindicated Combinations and Dosage Adjustments Antiretroviral Agent Management When Used with Rifabutin Nonnucleoside Reverse Transcriptase Inhibitors Efavirenz Use standard efavirenz dosage; increase rifabutin to 450-600 mg daily. Nevirapine Use standard dosage of nevirapine; give rifabutin at 300 mg daily or 3 times weekly. Delavirdine Do not combine. Ritonavir-Boosted Protease Inhibitors Lopinavir/Ritonavir (Kaletra) All Other Ritonavir- Boosted PIs Give standard dosage of lopinavir/ritonavir; decrease rifabutin to 150 mg alternate days or 3 times weekly. Give standard dosage of PI/ritonavir; decrease rifabutin to 150 mg on alternate days or 3 times weekly. Unboosted Protease Inhibitors Ritonavir Use ritonavir at standard dosage; give rifabutin at 150 mg on alternate days or 3 times weekly. Amprenavir, Fosamprenavir Use PIs at standard dosages; give rifabutin at 150 mg/day or 300 mg 3 times weekly. Atazanavir Give atazanavir at standard dosage; give rifabutin at 150 mg on alternate days or 3 times weekly. Indinavir Increase indinavir to 1,000 mg every 8 hours; give rifabutin at 150 mg/day or 300 mg 3 times weekly. Nelfinavir Increase nelfinavir to 1,000 mg every 8 hours; give rifabutin at 150 mg/day or 300 mg 3 times weekly. Ritonavir Give ritonavir at standard dosage; give rifabutin at 150 mg on alternate days or 3 times weekly. Source: HIV InSite. Database of Antiretroviral Drug Interactions. San Francisco: UCSF Center for HIV Information. Available online at http://hivinsite.ucsf.edu/arvdb?page=ar-00-02. Accessed April 26, 2006. The patient should show clinical improvement within the first weeks of treatment. If the patient is not responding to treatment after 2-4 weeks of therapy, assess adherence, consider adding 1 or more drugs, and consider evaluation for other or additional causes of the patient’s symptoms. Consider repeating a blood culture with antimicrobial sensitivities in patients whose clinical status has not improved after 4-8 weeks of treatment. If immune reconstitution inflammatory reactions are suspected, consider adding anti-inflammatory medications (see chapter Immune Reconstitution Syndrome). Section 6—Disease-Specific Treatment | 6–63 Treatment of MAC is generally required for the remainder of the patient’s life, although it may be reasonable to discontinue MAC therapy if patients complete at least 12 months of MAC treatment, have no further symptoms, and demonstrate immune restoration in response to ART (an increase in CD4 counts to >100 cells/µL for at least 6 months). If MAC treatment is discontinued, the patient must be monitored carefully for any decrease in CD4 cell count or recurrence of MAC symptoms. Some clinicians verify negative AFB cultures before discontinuing therapy. Treatment should be resumed if the CD4 count drops to 50-100 cells/µL in response to ART. Patients must take all medicines exactly as prescribed. If doses are missed, or if the medication is stopped and restarted, Mycobacterium can develop resistance to the medications. If patients are having trouble taking the medications on schedule, they should contact their health care providers immediately. Educate patients about the benefits of ART in strengthening the immune system and preventing opportunistic infections such as DMAC. Urge patients to contact the clinic immediately if they notice worsening symptoms, or new symptoms. DMAC is an opportunistic infection of late-stage HIV and indicates profound immune suppression. Some patients may not respond to MAC treatment or to ART. Because this is a life-threatening disease, clinicians should discuss advance directives and durable power of attorney with patients. Referral to a social worker, mental health clinician, or chaplain experienced in such issues may facilitate this discussion.
6–64 | Clinical Manual for Management of the HIV-Infected Adult/2006 References ♦ ♦ ♦ ♦ ♦ ♦ 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. Centers for Disease Control and Prevention. Recommendations on prophylaxis and therapy for disseminated Mycobacterium avium complex for adults and adolescents infected with human immunodeficiency virus. U.S. Public Health Service Task Force on Prophylaxis and Therapy for Mycobacterium avium Complex. MMWR Recomm Rep. 1993 Jun 25;42(RR-9):14-20. Available online at www.cdc. gov/mmwr/preview/mmwrhtml/00021272.htm. Accessed May 19, 2006. Horsburgh CR Jr., Gettings J, Alexander LN, et al. Disseminated Mycobacterium avium complex disease among patients infected with human immunodeficiency virus, 1985-2000. Clin Infect Dis. 2001 Dec 1;33(11):1938-43. Jacobson MA, Aberg JA. Mycobacterium avium Complex and Atypical Mycobacterial Infections in the Setting of HIV Infection. In: Peiperl L, Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]. San Francisco: UCSF Center for HIV Information; 2006. Accessed April 15, 2006. 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. 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.
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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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♦ ♦ ♦ ♦ ♦ | 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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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Patient Education ♦ ♦ ♦ ♦
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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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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Page 246 and 247: Cervical Dysplasia Background Cervi
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Page 254 and 255: Cryptosporidiosis Background Crypto
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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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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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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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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