I am JaKePositive...I am a Homosexual...I am a Filipino...I am a Proud Ilonggo... I am HIV + since June 2010... I started my ARV Treatment May 4,2013 since my CD4 dropped to 107... I am here to RAISE AWARENESS... I am here to ENCOURAGE HIV TESTING... I am here to SUPPORT MY BROTHER'S and SISTER'S who are living with HIV... I am an ADVOCATE FOR CHANGE...

Monday, October 1, 2012

GUIDELINES FOR ANTIRETROVIRAL TREATMENT

 


 The decision to start a patient on ARV will be based on the clinical findings and/or CD4 level determination. The benefits, toxicity, adherence issues and costs of the treatment must be a component of counseling.

Criteria for Initiation of ARV
WHO Clinical Staging
CD4 Testing NOT AVAILABLE
CD4 Testing  AVAILABLE
STAGE 1 – ASYMPTOMATIC
DO NOT TREAT
TREAT if CD4 is BELOW 200 cells/mm3
STAGE 2 – MILD
DO NOT TREAT
TREAT if CD4 is BELOW 200 cells/mm3
STAGE 3 – ADVANCED
TREAT
Consider TREATMENT if CD4 is BELOW 350 cells/mm3 and initiate TREATMENT before CD4 falls below 200 cells/mm3
STAGE 4 – SEVERE
TREAT
TREAT irrespective of CD4 Count

 


WORLD HEALTH ORGANIZATION

CLINICAL STAGING OF HIV and AIDS

CLINICAL STAGE 1
Asymptomatic
Persistent Generalized Lymphadenopathy
CLINICAL STAGE 2
Unexplained moderate weight loss (under 10% of presumed or measured body weight)
Recurrent Upper Respiratory Tract Infections (Sinusitis, Tonsillitis, Otitis Media, Pharyngitis)
Herpes Zoster
Angular Cheilitis
Recurrent Oral Ulcerations
Papular Pruritic Eruptions
Seborrheic Dermatitis
Fungal Nail Infection
CLINICAL STAGE 3
Unexplained severe weight loss ( over 10% of presumed or measured body weight)
Unexplained Chronic Diarrhea for longer than one month
Unexplained Persistent Fever (intermittent or constant for longer than one month)
Persistent Oral Candidiasis
Oral Hairy Leukopakia
Pulmonary Tuberculosis (current)
Severe Bacterial Infections (e.g. Pneumonia, Empyema, Pyomyositis, Bone or Joint Infection, Meningitis, Bacteremia, Severe Pelvic Inflammatory Disease)
Acute Necrotizing Ulcerative Stomatitis, Gingivitis, Periodontitis
Unexplained Anemia (below 8g/dl), Neutropenia (below 0.5 x 109 / 1) and/or Chronic Thrombocytopenia (below 50 x 109 / 1)
CLINICAL STAGE 4
HIV Wasting Syndrome
Pneumocystis Pneumonia
Recurrent Bacterial Pneumonia
Chronic Herpes Simplex infection (Orolabial, Genital or Anorectal for more than one month’s duration or visceral at any site)
Esophageal Candidiasis (or Candidiasis of Trachea, Bronchi or Lungs)
Extrapulmonary Tuberculosis
Kaposi Sarcoma
Cytomegalovirus Infection (Retinitis or Infection of other organs)
Central Venous System Toxoplasmosis
HIV Encephalopathy
Extrapulmonary Cryptococci's incliding Meningitis
Disseminated Non-Tuberculosis Mycobacterial Infection
Progressive Multifocal Leukoencephalopathy
Chronic Cryptosporidiosis
Chronic Isosporiasis
Disseminated Mycosis (Coccidiomycosis or Histoplasmosis)
Recurrent Septicemia (including Non-Typhoidal Salmonella)
Lymphoma (Cerebral or B Cell Non-Hodgkin)
Invasive Cervical Carcinoma
Atypical Disseminated Leishmaniasis
Symptomatic HIV-Associated Neuropathy or HIV-Associated Cardiomyopathy


ANTIRETROVIRAL DRUGS: DOSES, INSTRUCTIONS, ADMINISTRATION, IMPORTANT ADVERSE REACTION

DRUG DOSE ADMINISTRATION IMPORTANT ADVERSE REACTIONS

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI’s)

Zidovudine

(ZDV or AZT)


300mg Tablets
300mg every 12 hours take without regard to meals Anemia, Leukopenia,

Lactic Acidosis (rare)
Lamivudine (3TC)

150mg Tablets
150mg every 12 hours
or 300mg once daily
take without regard to meals Well tolerated
Stavudine (d4T)

30mg Tablets
30mg every 12hours irrespective of body weight take without regard to meals Pancreatitis

Lactic Acidosis

Severe Hepatomegally
with Steatosis

Rapidly Progressing Ascending Neuromuscular Weakness
Didanosine (ddI)
200mg Entric Coated Capsules

250mg Entric Coated Capsules

400mg Entric Coated Capsules
Body weight: >60kg
400mg once daily
with TDF:
250mg once daily

Body weight: <60kg
250mg once daily
with TDF:
200mg once daily
Must be taken on an empty stomach Pancreatitis

Lactic Acidosis

NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

Tenofovir (TDF)
300mg Tablets
300mg once daily take without regard to meals Nephrotoxicity

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIs)

Efavirenz (EFV)
600mg Tablets
600mg once daily Take on an empty stomach and before bedtime as severe dizziness is possible upon initiation of therapy that resolves or becomes tolerable after a few days Rash

Hepatitis
Nevirapine (NVP)

200mg Tablets
As severe hypersensitivity may develop during initiation, trial period should be done by giving 200mg once a day x 14days together with the full dose of NRTI. If there is no sign of hypersensitivity, then give full dose at 200my every 12hours. Take without regard to meals

Not recommended to be co-administered with Rifampicin.
STOP if any of these are observed:
1. Fever or Feverish Sensation
2. Flu-like Symptoms such as muscle or body pains
3. Disseminated Macular or Maculopapular or Urticarial rashes

In case of mild skin rashes such as discreet papular or nodular rashes that are limited in number, without other signs, continue NVP and observe for any progression.

Serious hepatic events have been reported among treatment-naïve with pre-Nevirapine CD4 counts >250 cells/mm3 or in treatment-naïve male patients with pre-Nevirapine CD4 counts >400 cells/mm3

PROTEASE INHIBITORS (PI’s)

Indinavir (IDV)
400mg Capsules
800mg every 12hours to be given with Ritonavir 100mg every 12hours For RTV-boosted IDV take with or without food

Take with plenty of water to avoid Nephrolithiasis.

Not recommended to be co-administered with Rifampicin
Nephrolithiasis
Ritonavir (RTV)

100mg Capsules
100mg every 12hours to be given with Indinavir 800mg every 12hours or Sauinavir 1000mg every 12hours For RTV-boosted IDV take with or without food

For RTV-boosted SQV take within 2hours of a meal

Not recommended to be co-administered with Rifampicin
Hepatitis

Lipodystrophy
Lopinavir / Ritonavir (LPV/r)

Lopinavir 200mg/Ritonavir 50mg Tablets
2 tablets every 12hours Take without regard to meals

Not recommended to be co-administered with Rifampicin
Gastro Intestinal Intolerance

Lipodystrophy
Nelfinavir (NFV)

250mg Tablets 625mg Tablets
1250mg every 12hours
750mg every 8hours
Take with meal or snack

Not recommended to be co-administered with Rifampicin
Gastro Intestinal Intolerance

Lipodystrophy
Saquinavir (SQV)
500mg Tablets
1000mg every 12hours to be given with Ritonavir 100mg every 12hours Take within two hours of a meal

Not recommended to be co-administered with Rifampicin
Gastro Intestinal Intolerance

Lipodystrophy

FIXED DRUGS COMBINATIONS

Lamivudine (3TC) + Stavudine (d4T)

3TC 150mg + d4T 30mg Tablets
1 Tablet every 12hours Take without regard to meals See Lamivudine and Stavudine above
Zidovudine (ZDV) + Lamivudine (3TC)

ZDV 300mg + 3TC 150mg Tablets
1 Tablet every 12hours Take without regard to meals See Zidovudine and Lamivudine above
Zidovudine (ZDV) + Lamivudine (3TC) +
Nevirapine (NVP)


ZDV 300mg + 3TC 150mg + NVP 200mg Tablets
1 Tablet every 12hours Take without regard to meals

Not recommended to be co-administered with Rifampicin
See Zidovudine, Lamivudine and Nevirapine above
Emtricitabine (FTC) + Tenofovir (TDF) + Efavirenz (EFV)

FTC 200mg + TDF 300mg + EFV 600mg Tablets
1 Tablet once daily Take on an empty stomach and before bedtime See Tenofovir and Efavirenz above.

Emtricitabine – minimal toxicity, rare cases of lactic acidosis



IMPORTANCE OF ADHERENCE COUNSELING
HIV can develop resistance to ARV’s. The success of ARV Therapy largely depends on patient’s adherence to treatment. A 95% adherence rate is required to prevent the development of drug resistance.

LABORATORY TESTS PRIOR TO INITIATING ARV TREATMENT
Complete Blood Count (CBC)
Chest X-Ray, Sputum Acid Fast Bacilli (AFB) and Sputum Culture to rule out Active Tuberculosis
Pregnancy Test for Females of Reproductive Age
Baseline Urinalysis, Fasting Blood Sugar (FBS), Liver Function Tests, Creatinine, and Lipid Profile when indicated

MONITORING FOR ARV TOXICITY

For Zidovudine (AZT) + Lamivudine (3TC) + Efavirenz (EFV) / Nevirapine (NVP)
Complete Blood Count (CBC) – every month for the first 3 months and every 4-6 months thereafter
SGPT, SGOT, Alkaline Phosphatase, Amylase – after 1 month, after 6 months and every 12 months thereafter
For Tenofovir (TDF) + Lamivudine (3TC) + Efavirenz (EFV) / Nevirapine (NVP)
Creatinine and Urinalysis – Annually
SGPT, SGOT, Alkaline Phosphatase, Amylase – after 1 month, after 6 months and every 12 months thereafter
For Stavudine (d4T) + Lamivudine (3TC) + Efavirenz (EFV) / Nevirapine (NVP)
Complete Blood Count (CBC) – Annually
SGPT, SGOT, Alkaline Phosphatase, Amylase – after 1 month, after 6 months and every 12 months thereafter
Total Cholesterol, Triglyceride, Low Density Lipoprotein (LDL) – after 6 months and every 12 months thereafter
For Tenofovir (TDF) + Lamivudine (3TC) + Lopinavir / Ritonavir (LPV/r)
Creatinine and Urinalysis – Annually
Total Cholesterol, Triglyceride, Low Density Lipoprotein (LDL) – after 6 months and every 12 months thereafter
Fasting Blood Sugar (FBS) – after 6 months and every 12 months thereafter
For Zidovudine (AZT) + Lamivudine (3TC) + Lopinavir / Ritonavir (LPV/r)
Complete Blood Count (CBC) – after 1 month, after 6 months and avery 12 months thereafter
Total Cholesterol, Triglyceride, Low Density Lipoprotein (LDL) – after 6 months and every 12 months thereafter
Fasting Blood Sugar (FBS) – after 6 months and every 12 months thereafter
For Stavudine (d4T) + Lamivudine (3TC) + Lopinavir / Ritonavir (LPV/r)
Complete Blood Count (CBC) – Annually
SGPT, SGOT, Alkaline Phosphatase, Amylase – after 1 month, after 6 months and every 12 months thereafter
Total Cholesterol, Triglyceride, Low Density Lipoprotein (LDL) – after 6 months and every 12 months thereafter
Fasting Blood Sugar (FBS) – after 6 months and every 12 months thereafter


MONITORING RESPONSE TO TREATMENT
Trial of therapy for at least 6 to 12 months should be given before concluding that an ARV regimen is failing. For patients with good compliance to ART, clinical response is recommended to be used together with CD4 Count and Viral Load Determination (whenever available) to detect treatment failure.

CHANGE OF TREATMENT REGIMEN
Drug Toxicity and Side Effects
ARV Drugs are associated with side effects and long term toxicities. Although life threatening side effects had been reported, many side effects can be managed symptomatically. the ARV component causing toxicity should be identified and changed if necessary. The General Principle is that single-drug substitution because of toxicity should involve drugs belonging to the same ARV class.
It is also important to ask patients of intake of other medications because ARV’s may interact with these medications.

Treatment Failure
It is very important to regularly assess patients for treatment failure, determine the reasons for these and institute appropriate management immediately. If poor compliance is the cause of treatment failure then counseling for adherence must be intensified and the current regimen continued. Determination of CD4 Count should be performed after 3 months to reassess response to treatment.
Patients who are candidates for second-line ARV’s must be managed in close coordination with the Research Institute of Tropical Medicine or San Lazaro Hospital.

THESE INFORMATION IS JUST TO GIVE YOU AN IDEA ABOUT ARV TREATMENT. IT IS STILL BEST TO CONSULT YOUR DOCTOR ABOUT IT.



 JaKe Positive. BE SAFE! +)

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