05a melendez orrick arv complications

7/23/2019 05a Melendez Orrick Arv Complications

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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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'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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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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'actic Acidosis and Hepatic teatosis

As%mptomatic $%perlactatemia

%mptomatic $%perlactatemia


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'actic acidosis s%ndrome


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'actic acidosis s%ndrome


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'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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'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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ide !**ects H%perlipidemia 0reatment

P$armacologic HMB+CoA Red"ctase


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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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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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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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ide !**ects BI Intolerance


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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!

05a melendez orrick arv complications

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