02.03 adult art monitoring, changing gsn

UNIT 3 Monitoring/changing /stopping Highly Active Anti Retroviral Therapy (HAART) and drug interactions:

UNIT 3: Objectives ,[object Object],[object Object],[object Object],[object Object]

Monitoring Antiretroviral Therapy

Monitoring ART ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Clinical Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Clinical Monitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Clinical Monitoring: Indicators of Treatment Success ,[object Object],[object Object],[object Object],[object Object],[object Object]

Laboratory Monitoring of ART ,[object Object],[object Object],[object Object]

Laboratory Monitoring of ART: CD4 Count ,[object Object],[object Object],[object Object],[object Object],[object Object]

Laboratory Monitoring of ART: Viral Load ,[object Object],[object Object],[object Object],[object Object],[object Object]

Lab Tests: Monitoring For Toxicity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Lab tests: Follow up ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Summary Schedule of Laboratory Monitoring X X 1 X (if on TDF) X X 6m X X X Fasting lipids & glucose (PIs) X X X X (if on NVP) X (if on NVP) X ALT(LFT) X 1 X 1 X 1 X 1 X 1 X Pregnancy test X (if on TDF X (if on TDF) X (if on TDF X (if on TDF) X (if on TDF) X Serum Creatinine X X X X (if on AZT) X (if on AZT) X CBC + Differential X X X X CD4 24m 18m 12m 3m 1-2 months Baseline Test

Three Main Reasons for Altering a Patient’s Regime: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

1. Drug Toxicity and Intolerance ,[object Object],[object Object],[object Object]

Guidelines When to stop/change I ,[object Object],[object Object],[object Object],[object Object],[object Object]

Common “Mild” SE’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Common “Mild” SE’s ,[object Object],[object Object],[object Object]

Rare, potentially serious SE’s ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

A Rational Approach to the Management of Serious Side Effects Refer to “The National Clinical Manual for ARV Providers”

Rash ,[object Object],[object Object],[object Object],[object Object],[object Object]

Case Study - Rash ,[object Object],[object Object],[object Object]

Hepatotoxicity ,[object Object],[object Object],[object Object],[object Object],[object Object]

Case Study - Hepatotoxicity ,[object Object],[object Object]

Continued… ,[object Object],[object Object],[object Object],[object Object],[object Object]

Haematotoxicity ,[object Object],[object Object],[object Object],[object Object],[object Object]

Case Study - Haematotoxicity ,[object Object],[object Object],[object Object],[object Object]

Peripheral Neuropathy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Case Study - Neuropathy ,[object Object],[object Object],[object Object]

Continued… ,[object Object],[object Object],[object Object]

Pancreatitis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

First line ARV regimens ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

First line ARV regimens ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

First line ARV regimens ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

2. Drug Interactions It is not possible to remember all the possible drugs interactions with ARV’s Refer to “The National ARV Guidelines”

Main Problems ,[object Object],[object Object],[object Object],[object Object]

A. Blood levels of ARV’s Increased or Decreased ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

TB Drugs ,[object Object],[object Object],[object Object],[object Object],[object Object]

B. Drugs which are made Ineffective by ARV’s ,[object Object],[object Object]

C. Additive Toxicities ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

D. Incompatible ARV’s ,[object Object],[object Object],[object Object],[object Object],[object Object]

Minimizing Drug Interactions ,[object Object],[object Object],[object Object],[object Object],[object Object]

3. Treatment Failure Refer to “The National Clinical Manual for ARV Providers”

Diagnosing Treatment Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Immune reconstitution Inflammatory syndrome ,[object Object],[object Object]

CAUSES OF FAILURE OF ART: INFLUENCE OF FOOD ON ART ABSORPTION Drug Fasting Low High Recommen- fat meal fat meal dation Indinavir + + - Fasting Indinavir+Ritovinar) + + + None Nelfinavir - + + Meal Amprinavir + + - No High fat meal Navirapine + + + None Delavaridine + - - Fasting Efavirenz + + + none

CAUSES OF FAILURE OF ART: Pill Burden

CAUSES OF ART FAILURE: ADRs ,[object Object],[object Object],[object Object],[object Object],[object Object],AZT – Gastritis Anemia & Hepatitis d4T – Peripheral neuropathy NVP - Skin rash Hepatitis SJS PI - Lipodystrophy Renal failure Hepatitis We have not encountered lactic acidosis or Osteopenia/osteoporosis

CAUSES OF ART FAILURE: CONCOMITANT MEDICATION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CAUSES OF ART FAILURE: CONCOMITANT MEDICATION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Recommended second-line regimens in adults and adolescents for treatment failure on first-line ARV regimens ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Changing to 2 nd line Regime ,[object Object],[object Object],[object Object],[object Object],[object Object]

Summary ,[object Object],[object Object],[object Object]

02.03 adult art monitoring, changing gsn

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02.03 adult art monitoring, changing gsn

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