05a melendez orrick arv complications
TRANSCRIPT
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ARV Complications and
Management
Ivn Melndez Rivera, M.D.
F.A.A.F.P.A.A.H.I.V..
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Initial Medical !val"ation
#aseline P$%sical Condition
&e"rologic F"nction
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Initial Medical !val"ation
'a(oratories
C#C ) Di**., F#
'iver Pro*ile, Hepatitis pro*ile
'ipid Pro*ile, Renal *"nction
C"rrent Medications
Co+mor(id conditions
ver t$e co"nter
Alternative Medicine Prod"cts
Intraveno"s or recreational Dr"g -se
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Initial Medical !val"ation
C$ild (earing potential
!val"ate *or ad$erence
Assess patient no/ledge regardingmedications side e**ect
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&"cleoside and &"cleotide
Reverse 0ranscriptaseIn$i(itors
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&"cleoside1&"cleotide
2 FDA approved &"cleoside
3 FDA approved &"cleotide
4 *i5ed dose com(ination ta(lets
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Common &R0I6s ide !**ects
Mitoc$ondrial 0o5icit% D"e to &A in$i(ition o* mitoc$ondrial D&A
pol%merase responsi(le *or mitoc$ondrial
D&A s%nt$esis. Responsi(le *or lactic acidosis , $epatic
steatosis, m%opat$%, pancreatitis,perip$eral ne"ropat$% and lipoatrop$%.
Relative In$i(itor% Potenc%7ddC8ddI8d4089DV8:0C;A#C;0DF
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Common &R0I6s ide !**ects
'actic Acidosis and Hepatic teatosis
As%mptomatic $%perlactatemia
%mptomatic $%perlactatemia
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Common &R0I6s ide !**ects
'actic acidosis s%ndrome
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Common &R0I6s ide !**ects
'actic acidosis s%ndrome
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Common &R0I6s ide !**ects
'actic Acidosis
0reatment
IV *l"id6s
D1C ARV #icar(onate7 correct acidemia
Ri(o*lavin @ mg1da%, t$iamine, coenz%me E
Antiretroviral rec$allenge
Ins"**icient data
First doc"ment normal lactate level : mos.
Consider A#C, :0C, F0C, or 0DF regimen
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Common &R0I6s ide !**ects
'ipod%strop$%
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Fat Redistri("tion
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A(acavir
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A#C H%persensitivit%
0r"e A#C H%persensitivit% /ill
e5perience /orsening s%mptoms /it$
eac$ dose
A#C H%persensitivit% Registr%7
G+?2+4?@
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&on &"cleoside Reverse
0ranscriptase In$i(itors
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Common &&R0I ide !**ects
RAH cc"rs d"ring *irst /ees or later in t$e
treatment
Presentation Di**"se mac"lopap"lar, er%t$emato"s and
pr"ritic.
I* accompanied (% *ever, (listering, oral
lesions, conK"nctivitis, s/elling, m"scle orKoint ac$es co"ld (e tevens+Lo$nsons%ndrome
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Common &&R0I6s ide
!**ects RAH
0reatment
Most o* t$em resolve /it$ d1c medication
P$armacologic
Dip$en$%dramine, $%dro5%zine
Corticosteroids
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!*avirenz
Dizziness
Impaired Concentration
leep dist"r(ance !arl% Insomnia
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!*avirenz
A(normal Dreams
An5iet%1 Agitation1 &ervo"sness
Depression %mptoms resolve over time
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&evirapine
Hepatoto5icit% As%mptomatic A01A'0 elevations 8@
times "pper normal limit
N#lac #o5O *atal $epatoto5icit% incl"ding*"lminant and c$olestatic $epatitis, $epaticnecrosis and $epatic *ail"re
Hepatoto5icit% %mptoms
&on+speci*ic *l" lie illness, *atig"e, malaise,anore5ia, na"sea, Ka"ndice
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Delavirdine
M"ltiple dr"g+dr"g interactions
Fatig"e
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PR0!A! I&HI#I0R
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Common Protease In$i(itor
ide !**ects 'ipod%strop$% Fat Maldistri("tion Hepatoto5icit% < A0,A'0,BB0=
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Common Protease In$i(itor
ide !**ects H%pergl%cemia :+32 on PI t$erap% at da%s
Ca"ses7 Perip$eral and $epatic ins"lin resistance
Bl"t 4 de*icienc%
Red"ction or in$i(ition o* gl"coneogenesis
Famil% $istor% o* Dia(etes
Medications
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Insulin Resistance
Adapted with permission from Saltiel AR, Olefsky JM. Diabetes. !!"#$%&""
Perip$eral 0iss"e
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ite o* action o* oral $%pogl%cemic dr"gs
Bl"cose "ptae
Pancreas
'iver M"scle
B"t
Rosiglitazone
HBP
"l*on%l"rea
Pioglitazone
MeglitinideMiglitol
Impaired ins"linsecretion
Ins"linde*icienc%
; Car(o$%drate meta(olism
Acar(ose
Met*ormin
Ins"linresistance;
H%pergl%cemia
!5ogeno"s ins"lin R5
a(is S-. Postgrad Med. ///#"
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Common Protease In$i(itors
ide !**ects H%perlipidemia
Increase C$ol., 'D'+C, 0rigl%cerides
Decrease HD'+C Ris *actors
Male
84
smoer *amil% $istor% o* dia(etes
H%pertensive Vasc"lar Disease
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Common Protease In$i(itors
ide !**ects H%perlipidemia 0reatment
P$armacologic HMB+CoA Red"ctase
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Common Protease In$i(itors
ide !**ects Increased #leeding !pisodes inHemop$iliacs
!tiolog% "ncertain cc"rs in t$e *irst mont$ o* t$erap%
0reatment
Constant monitoring o* prot$om(in time
Additional coag"lation *actor i* needed
/itc$ing AR0
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Common Protease In$i(itors
ide !**ects steopenia and steoporosis Decrease in (one mineral densit%
Most common site is *emoral $ead
Ris *actors
H%perlipidemia, alco$ol a("se, '!, c$ronic steroid "se,
$%percoag"la(le states, post menopa"sal /omen
ings and %mptoms
'imping
Persistent pain in related area
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Common Protease In$i(itors
ide !**ects steopenia and steoporosis !val"ation7 C0 or MRI
0reatment &on p$armacologic
eig$t+(earing e5ercise
AdeQ"ate intae o* Calci"m and Vit. D
"rger% P$armacologic
#ip$osp$onates, ralo5i*ene or calcitonin
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Common Protease In$i(itors
ide !**ects BI Intolerance
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Common Protease In$i(itors
ide !**ects BI Intolerance 0reatment7 P$armacologic
Antiemetic agents7 metoclopramide,p$enot$iazine class
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vervie/ o* #ilir"(in Prod"ction and Meta(olism
Indirect
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'opinavir1ritonavir
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!&0RU I&HI#I0R
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!n*"vertide
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Management o* ide !**ects
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An5iet%1Agitation1
&ervo"sness P$armacologic
An5iol%tics lie lorazepam, clonazepam
'o/ dose ne"roleptic medication
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An5iet%1Agitation1
&ervo"sness &on p$armacologic
!val"ate *or ot$er ca"ses incl"ding
ps%c$iatric or s"(stance "se
Avoid7 stim"lant *ood
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#one Marro/ 0o5icit%
P$armacologic
I* Hg2.@ dose interr"ption
#lood 0rans*"sion
!poetin al*a *or anemia
B+CF or BM+CF *or ne"tropenia
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Distal %mmetrical
Pol%ne"ropat$% P$armacological
Decrease d40 or ddI dose, i* persist D1C
&on pioid , ea opioid, trong opioid 0ric%clic Antidepressants
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Distal %mmetrical
Pol%ne"ropat$% &on p$armacologic
#+3? Vitamin
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Dizziness
P$armacologic
Antivert or Dramamine
&on P$armacologic
0ae ARV medication at (ed time
r 3?+3@ $r (e*ore need to (e *"nctional
!val"ate *or !&0 disorders
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Fatig"e
&on P$armacologic
&"trition
!5ercise
DH!A leep $%giene
Determine co mor(id conditions and 05.
P$armacologic
Hormone replacement7 0estosterone
Bro/t$ Hormone
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BI Intolerance
P$armacologic
Antiemetic
&on P$armacologic
0aing medication /it$ *ood
Hone% @ml (e*ore pills
Care*"l in patient /it$ less t$an ? CD4
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Headac$es, Malaise
P$armacologic
Analgesic
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Hepatoto5icit%
&on p$armacologic Monitor liver *"nction test care*"ll% d"ring t$e
*irst 3 /ees o* treatment Monitor patient *or s%mptoms s"ggestive o*
$epatitis incl"ding liver tenderness or$epatomegal% C$ec #aseline 'F0 and Hepatitis stat"s tart medication in lo/er dose
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H%per(ilir"(inemia
&on P$armacologic
Plent% o* /ater
"n e5pos"re
P$armacologic
&one
Do not red"ce dose
/itc$ AR0
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H%persensitivit% Reaction
P$armacologic
D1C A#C
IV Fl"ids and Vasopressors
&o p$armacologic agents $ave (een identi*ied *orprevention
&on P$armacologic
!d"cate patient a(o"t signs and s%mptoms
Patient arning Card
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Impaired Concentration
&on P$armacologic
Avoid m"ltitasing sit"ations
-tilize appointment (oos, calendar, note
pads
Bingo (ilo(a
P$armacologic
&o proven medication
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M%opat$%
P$armacologic
D1C Medications
Prednisone
Carnitine s"pplement
Antio5idants7 Vit A and !
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&ep$rolit$iasis
0reatment
&on p$armacologic
Plent% o* /ater
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ral1esop$ageal -lcers
P$armacologic
NPeride5O mo"t$ /as$
0riamcinolone oral (ase
Intralesional steroid inKection
0$alidomide
&on+p$armacologic
D1C o**ending agent
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Pancreatitis
P$armacologic "spend ddI /$en clinical signs present
IV Fl"ids Hig$ Vol"me
&on P$armacologic earc$ *or alco$ol "se
Prevent concomitant administration o*7
valproic acid, t$iazide, *"rosemide,pentamidine, s"l*onamides, tetrac%cline,metronidazole
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leep Dist"r(ance
P$armacologic
!arl% Insomnia $ort acting sedative
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leep Dist"r(ance
&on P$armacologic Avoid stim"lant *ood
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THANKS!