Special Issues with Antiretroviral Therapy (PowerPoint)

Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents V - Special Issues AETC NRC Slide Set Version 1.0, February 2001 AETC Disclaimer These slides were developed using the most recent treatment guideline information at the time of production. However, in the rapidly changing field of HIV care this information could become out of date quickly. The user is encouraged to compare the date of this slide set with the date of the most recent guidelines. Also, it is intended that these slides be used, as prepared, without changes in either content or attribution. Users are asked to honor this intent. -AETC NRC AETC V. Special Issues: Contents • • • • • Acute HIV infection Advanced HIV infection Adolescents Interruption of therapy Adherence AETC Acute HIV Infection AETC Acute Retroviral Syndrome: Signs and Symptoms - I • • • • • • Fever Lymphadenopathy Pharyngitis Rash Myalgia or arthralgia Diarrhea 96% 74% 70% 70% 54% 32% AETC Acute Retroviral Syndrome: Signs and Symptoms - II • • • • • • Headache Nausea and Vomiting Hepatosplenomegaly Weight Loss Thrush Neurological Symptoms 32% 27% 14% 13% 12% 12% AETC Acute Retroviral Syndrome: Rash • Erythematous maculopapular with lesions on the face and trunk and sometimes extremities including palms and soles • Mucocutaneous ulceration involving mouth, esophagus or genitals (distinguishes HIV from mononucleosis (EBV)) AETC Acute Retroviral Syndrome: Neurological Symptoms • Meningoencephalitis or aseptic meningitis (uncommon) • Peripheral neuropathy or radiculopathy • Facial palsy • Guillain-Barre syndrome • Brachial neuritis • Cognitive impairment or psychosis AETC Early Intervention Theory • • • • • • • Should be limited to the clinical trial setting Suppress the initial burst of viral replication Decrease the severity of acute disease Alter the viral “set point” Reduce the rate of mutation Reduce risk of viral transmission Preserve immune function AETC Risks and Benefits of Delayed Initiation of Therapy BENEFITS • Avoid negative effects on quality of life • Avoid drug-related adverse events • Delay in development of drug resistance • Preserve maximum number of available and future drug options when HIV disease risk is highest RISKS • Possible risk of irreversible immune system depletion • Possibly greater difficulty in suppressing viral replication • Easier to transmit HIV to others AETC Risks and Benefits of Early Therapy BENEFITS • Control of viral replication easier to achieve and maintain • Delay or prevention of immune system compromise • Lower risk of resistance with complete viral suppression • Decreased risk of HIV transmission RISKS • Drug-related reduction in quality of life • Greater cumulative drugrelated adverse events • Earlier development of drug resistance, if viral suppression is sub optimal • Limitation of future antiretroviral treatment options AETC Primary HIV Infection Treatment Regimen • Same as chronic infection AETC The Patient With Advanced Disease AETC Treatment of the Patient With Advanced HIV Disease • Offer to all with AIDS and patients with symptomatic HIV infection with thrush or unexplained fever AETC Clinical Issues in the Patient With Advanced HIV Disease • • • • Drug toxicity Ability to adhere Drug interactions Laboratory abnormalities AETC Advanced HIV Infection • Often complicated drug regimens • Wasting and anorexia • Co-infection AETC Treatment of the Patient with Advanced HIV Disease • Recovery of immune function • Immune reconstitution syndromes : Immunologic response to sub-clinical pathogen, e.g.: MAC or CMV • Immune reconstitution syndromes are different from clinical failure • Treat new opportunistic infections AETC The HIV Infected Adolescent • Timing of infection; perinatal vs. acquired as an adolescent • Early intervention AETC The HIV Infected Adolescent • Normal adolescent development • Drug pharmacology in puberty • Dosing based on Tanner stages AETC Interruption of Antiretroviral Therapy AETC Interruption of Antiretroviral Therapy • • • • • Intolerable side effects Drug interactions First trimester pregnancy Unavailability of drugs Numerous other possible causes AETC Interruption of Antiretroviral Therapy • Stop all antiretroviral medications at once AETC Adherence AETC Adherence • The “rule” of thirds… – 1/3 take medication as prescribed – 1/3 are intermittently adherent – 1/3 take little or no medication AETC Who Will Be Adherent? • Age, race, sex, socioeconomic level educational level, socioeconomic status, and a past history of alcoholism or drug use are not reliable predictors of poor adherence AETC Adherence – Predicting Success • The more severe the symptoms or illness the better adherence • Improved adherence if patients believe in efficacy of treatment AETC Predicting Poor Adherence • Active drug use or alcoholism • Unstable housing, mental illness, and major life crises AETC Adherence – Keep It Simple • Once daily therapy - 90% adherence • Twice daily therapy - 80% adherence • Three or more times daily - 65% adherence AETC Improving Adherence • • • • • A trusting provider-patient relationship Education Development of treatment plan with patient Social support network Simple regimen AETC Adherence in Special Populations • • • • • Flexible clinic hours Accessible clinical staff Incentives Bilingual staff Adherence discussion during support groups • Individualized adherence programs • Others? AETC Adherence Strategies • • • • • • Negotiate a treatment plan Assess patient readiness Educate Reminder devises Social support Others? AETC Poor Adherence – Now What? • Increase the intensity of clinical follow up • Shorten the follow up interval • Recruit additional health team members – Mental health – Chemical dependency counselor – Others • Involve family and friends • Take a break AETC Poor Adherence – Now What? • Simplify dosing schedule – ddI – Nevirapine – Dual PI AETC Simplified Dosing Strategies NRTIs Initially recommended dose (mg) ddI 200 BID Amended dose (mg) 400 QD (pill, suspension) 300 BID AZT 100 five times a day AZT + 3TC AZT 300 BID 3TC 150 BID AZT 300 BID 3TC 150 BID ABC 300 BID 1 (300/150) pill BID (Combivir) 1 (300/150/300) pill BID (Trizivir) AZT + 3TC + ABC AETC Simplified Dosing StrategiesNNRTIs Initially recommended dose (mg) Amended dose (mg) NVP EFV 200 BID 600 QD 400 QD No change AETC Simplified Dosing Strategies - PIs Initially recommended dose (mg) RTV* + SQV-HCG* or + SQV-SGC* 600 BID (escalating) 600 TID* 1,200 TID* Amended dose(mg) No change 400 RTV + 400 SQV BID + IDV* 800 TID* 400 RTV + 400 IDV BID or 200 RTV + 800 IDV BID 200 RTV + 600 AMP 1,250 BID* + AMP* NFV * dose as single agent 1200 BID* 750 TID* AETC Web Sites to Access the Guidelines • www.aids-ed.org • www.hivatis.org