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

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02.03 adult art monitoring, changing gsn

  • 1. UNIT 3 Monitoring/changing /stopping Highly Active Anti Retroviral Therapy (HAART) and drug interactions:
  • 2.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11.
  • 12.
  • 13.
  • 14. 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
  • 15.
  • 16.
  • 17.
  • 18.
  • 19.
  • 20.
  • 21.
  • 22. A Rational Approach to the Management of Serious Side Effects Refer to “The National Clinical Manual for ARV Providers”
  • 23.
  • 24.
  • 25.
  • 26.
  • 27.
  • 28.
  • 29.
  • 30.
  • 31.
  • 32.
  • 33.
  • 34.
  • 35.
  • 36.
  • 37.
  • 38. 2. Drug Interactions It is not possible to remember all the possible drugs interactions with ARV’s Refer to “The National ARV Guidelines”
  • 39.
  • 40.
  • 41.
  • 42.
  • 43.
  • 44.
  • 45.
  • 46. 3. Treatment Failure Refer to “The National Clinical Manual for ARV Providers”
  • 47.
  • 48.
  • 49.
  • 50.
  • 51. 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
  • 52. CAUSES OF FAILURE OF ART: Pill Burden
  • 53.
  • 54.  
  • 55.
  • 56.
  • 57.
  • 58.
  • 59.

Notes de l'éditeur

  1. X1: If clinically indicated Serum Creatinine not needed for standard 1 st line; required more regularly in patients on TDF. Red X are for tests necessitated by those particular drugs. Most patients can be adequately monitored 6 monthly and as clinically indicated
  2. Average CD4 count rise