คำถาม aids ที่พึงรู้.pdf
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1. GPO vir-Z 250 ?1. GPO vir-Z 250
1. AZT( Zidovudine ) 250 mg
2. 3 TC( Lamivudine) 150 mg
3. NVP (Nevirapine) 200 mg
1. , , , , . . Thai Pharm
Health Sci J 2009;4(2):202-207 2. . . 2553
(National guides on HIV/AIDS Diagnosis and treatment Thailand 2010). ;2553
3.http://dpc 9.ddc.moph.go.th/napha 9/ sudya.html #8 :Accessed May 02, 2013
2. GPO vir s 40 ?1. GPO vir S30 S40
GPO VIR S40 - nevirapine : 2-3 ,
1-2 18 1-3 - lamivudine : - stavudine : 2-6
stavudine 1
CD4+
CD4+ 50 copies/ 6
CD4+ 3-4 CD4+ 100-150 /
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2
3. ARV ?
NRTIs(Nucleoside Reverse
Transcriptase Inhibitor)
NNRTIs(Non Nucleoside Reverse Transcriptase Inhibitor)
PIs(protease inhibitors)
AZT (Zidovudine)d4T ( Stavudine )3TC ( Lamivudine)
ddI ( Didanosine)ABC ( Abacavir)
TDF ( Tenofovir )FTC ( emtricitabine)ddC ( Zalcitabine)
NVP ( Nevirapine)
EFV ( Efavirenz )
DVL ( Delavirdine )
Etravirine (ETR)
IDV ( Indinavir )RTV ( Ritronavir )SQV ( Saquinavir )
LPV/RTV (Lopinavir/Ritronavir )NFV ( Nelfinavir )ATV ( Atazanavir )
APV ( Amprenavir)FPV ( Fosamprenavir )
Integrase inhibitors FIs
(fusion inhibitor)
CCR5-antagonist
- Raltegravir (RAL ENF ( Enfuvirtide) - Maraviroc
Vicriviroc,
1. NRTIs side chain nucleosides (thymidine,adenosine, cytidine) phosphorylation mono-,di-, triphosphate compound HIV-RT(inhibitory competitor) DNA (chain terminator)
(monotherapy) 0.3-0.7 log10 10 100,000 . . nucleoside RTI monontherapy ( AZT
ddI) 10,000 . .
2.NNRTIs NNRTIs noncompetitive nativenucleotides HIV-1 RT (downsteam) catalytic site NNRTIs metabolize NNRTIs 1-2
(favorable adherence)
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3.PIs HIV-1 protease enzyme HIV-1 2 (symmetrical isomer) (amino acids) 99 gag-polpolypeptide precursor immature HIV-1 mature infectious
4.FIs Glycoprotein HIV-1 2 gp120 gp41 gp120 CD4 gp41 fusion
transcription translation gp41 trimer trimer-hairpin hydrophobic grooves HR1 3 stable six-helix bundle fusion fusion pore
hairpin fusion5. CCR5-antagonist CCR5 receptor CD4+ cell HIV
4.Guideline AIDS
1. . .2553National Guidelines on HIV/AIDS Diagnosis and Treatment:Thailand 2010
2. Antiretroviral therapy for HIV infection in adults and adolescents Recommendations for a
public health approach 2010 revision : World Health Organization 2010
3. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
Source: 2012 The Department of Health and Human Services (DHHS) Antiretroviral Therapy Guidelines.
AIDS Info (aidsinfo.nih.gov)
4. Antiretroviral Treatment of Adult HIV Infection: 2012 Recommendations of the International
Antiviral Society-USA Panel
5. Opportunistic Infections Bacteria, Viral, Fungal
1.Candidiasis mucosal candidiasis (oropharyngeal candidiasis, cervicovaginal candidiasis,esophageal candidiasis diaper dermatitis ; )
Primary prophylaxis ;
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Secondary prophylaxis
mucosal candidiasis /
ADR : Fluconazole: N/V, GI side effect
Clotrimazole:
,
Nystatin: N/V, Diarrhea
Itraconazole: N, V
2.Pneumocystic carinii pneumonia (PCP)
Pneumocystic (jiroveci) carinii CD4 < 200/mm3 1-2 crepitation
(congestive heart failure) (acute respiratory distress syndrome, ARDS)Lab
- CD4 < 200/mm3 - Arterial blood gas - A-a gradient
- Lactate dehydrogenase (LDH)
Bronchoveolar lavage (BAL)
PCP: Categorized
by PaO2 and A-a gradient
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*** 21 ***
Corticosteroid :
PaO2
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Primary prophylaxis
CD4< 200 2 wk AIDS-defining illness ( ) sulfa Dapzone 100 mg OD ( arylamine
) CD4 > 200 3
Secondary prophylaxis
Primary CD4 > 200 3
3.Cryptococcal Meningitis
Cryptococcus neoformans 5-8% prevalence in HIV-infected patients in developedcountries before widespread use of effective ART (14.31% in Thailand 3 )
Primary prophylaxis
(Fluconazole 400 mg PO q wk ( ***))
Secondary Prophylaxis
induction consolidation
- Fluconazole 200 mg PO OD ***
- Amphotericin B 0.6-1 mg/kg IV 1-3 times/wk (multiple relapse on azoles)
- Itraconazole cap 200 mg PO od
CD4 100-200/mm3 6
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4.Cytomegalovirus (CMV)
retinitis
induction thx (BID) --> maintenane(OD) 2-3 wk
Primary prophylaxis
Secondary prophylaxis
Valganciclovir 900 mg PO OD
Ganciclovir 5 mg/kg IV Ganciclovir intravitreous 200 g 1-2
CD4 > 100-150 6
5.Toxoplasmic encephalitis (TE) Toxoplasmosis
Toxoplasma gondii (intracellular protozoan) hemiparesis, CN plasy
stiff neck conscious
pyrimethamine 200 mg -->50 -100 mg/d+ sulfadiazine 1-2 g 4 + folinic acid 10mg/day 6
pyrimethamine clindamycin 300-450 . 4
TMP-SMX 5-10 mg/kg/day TMP IV/PO
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Pyrimethamine clindamycin 600 mg 6-8 ( sulfadiazine )Pyrimethamine azithromycin 1,000-1,250 mg/day
Primary prophylaxis
CD4 < 100 IgG TMP/SMX SS 2 tab OD (prophylaxis PCP ) sulfa Dapzone 50 mg/day + pyrimethamine 50 mg/wk + folinic acid 25 mg/wk PO
CD4 > 200 3 Secondary prophylaxis
Sulfadiazine 0.5 g PO qid + pyrimethamine 50 mg/day + folinic acid 10 mg/day PO
CD4 > 200 6
6.TB
1) Rifampicin CYP450
efflux multi-drug transporter P-glycoprotein NNRTIs PIs 2) IRIS
IRIS IRIS
3) 4) 5)
Treatment of tuberculosis
2IRZE/4-7IR(I) 5-8 mg/kg (300 mg)
(R) 10 mg/kg (450-600 mg)
(E) 15-20 mg/kg (800-1,200 mg)(Z) 20-30 mg/kg (1,000-1,500 mg)
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S 10-15 mg/kg ( 1,000 mg) IM OD R R R Pls
2 9 DOT ( . . .) pyridoxine (B6)25-50 mg INH
rifampicins 2 IE OD 18 IE quinolone ofloxacin 12-18
Kanamycin 15 mg/kg (Max 1,000 mg) IM Amikacin 15 mg/kg (Max 1,000 mg) IM Ethionamide 15 mg/kg (500 -750 mg/day)
PO 2-3 Cycloserine 10 mg/kg (500 -750 mg/day)
PO 2-3 PAS(Para-aminosalicylic acid) 150 mg/kg (8,000-12,000 mg/day) PO 2 Ofloxacin 600 -800 mg/day Levofloxacin 500 -750 mg/day Moxifloxacin 400 mg/day
(Multi Drug ResistantTB: MDR-TB) INHrifampicin 3-4 1
(Extensively Drug Resistant TB: XDR-TB)
7.Mycobacterium Avium Complex (MAC)
CD4 < 50 cell/mm3 M. avium(95%) & M. intracellulare
GI 2
: acid-fast stain --> ( ) Bactec s.
Clarithromycin 500 mg 2 +ethambutol 15-25 mg/kg/dAzithromycin 500-600 mg/d + ethambutol 15-25 mg/kg/d
CD4 >100 6 MAC 12 Primary prophylaxis
CD4 < 50 CD4 Clarithromycin 500 mg PO BID Azithromycin 1000 - 1250 mg/wk
CD4 > 100 3
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Secondary prophylaxis
CD4 100 / . . MAC12 MAC
8. Histoplasmosis Penicillosis
Histoplasma capsulatum Penicillium marneffei = systemic mycosespenicilliosis -->papulonecrotic skin lesions histoplasmosis -->
papules, nodules
Induction phase : Amphotericin B 0.7 mg/kg/day 1-2 Consolidation phase : itraconazole 400 mg/day 10
Primary prophylaxis
CD4< 100Itraconazole 200 mg OD** ( cryptococcosis )
CD4 > 100 6 Secondary prophylaxis
Primary
CD4 > 100-150 6 **capsule solution
9. Herpes simplex and Herpes zoster
Herpes simplex ( )
Acyclovir 400 mg 3 famciclovir 250 mg 3 valacyclovir 1 g 2 5-10 5 14 Herpes zoster ( )
Acyclovir 800 mg 5 famciclovir 250 mg 3 valacyclovir 1 g 3 5-10
10. OIs GI
: 1 fresh smear2 Acid-fast stain
3 , .... Quinolones (norflox.) +metronidazole( Giardia , Entamoeba , diarrhea ATB)
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11 Cryptosporidiosis
Cryptosporidium epigastric cramping ( 10 /24 .)
antibiotics Erythromycin,Spiramycin, Paramomycin , ni antimotility agents loperamide 4 mg
diphenoxylate 5 mg
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6. Gold Standard Cryptococcal Meningitis 1. Lumbar puncture
- Intracranial pressure (ICP) - glucose- protein - +ve Cryptococcal Ag
- WBC 2. Lab
- CD4 < 100/mm3
- CSF: dark halo (india ink:60-80%)
- CSF: ICP, WBC < 20, / protein, / glucose, Crypto Ag > 1:8 (>95%)
7. Guideline AIDS Regimen 8. . regimen
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1 1 d4T( Stavudine ) + 3TC ( Lamivudine)+ NVP( Nevirapine) ( GPO-VIR ) 2 2.1 d4T( Stavudine ) + 3TC( Lamivudine) + EFV ( Efavirenz ) NVP(Nevirapine)
2.2 AZT(Zidovudine) + 3TC( Lamivudine) + NVP(Nevirapine) d4T(Stavudine) d4T < 50 copies/ml
d4T GPO-VIR S40 GPO-VIR S30 d4T, 3TC NVPd4T 15 20 mg 12
2.3 AZT + 3TC + EFV NVP d4T 3 3.1 d4T + 3TC + IDV / RTV
3.2 AZT + 3TC + IDV / RTV
9. New case ?CD4 CD4 3-6
*** -
- AZT - NVP (antihistamine)
( ) -
- AZT - NVP (antihistamine)
( )
*** (Drug interaction)
***
( 30 ) IDV
RTV SQV ( 2-8 ) RTV
(25 ) 1 SQV 3 2