Rubin_MDS218_final1 Managing Adverse Effects of HAART David Rubin, MD Clinical Assistant Professor of Medicine Weill Cornell Medical College Medical Director,

Slides:



Advertisements
Similar presentations
TB & HIV Infection: Treatment
Advertisements

TB & HIV Infection: Treatment Your name Institution/organization Meeting Date International Standard 8, 13 TB & HIV Infection: Treatment Your name Institution/organization.
ART in HIV-Infected Patients with TB: Research Priorities Group II Facilitator: David Cohn Rapporteur: Soumya Swaminathan.
Slide #1 HIV Entry Inhibitors Trip Gulick, MD, MPH Director, Cornell HIV Clinical Trials Unit Associate Professor of Medicine Weill Medical College of.
Antiretroviral Combinations James A Zachary MD LSU Health Sciences Center HIV Outpatient Clinic December 13, 2004
KITSO AIDS Training Program
HAART Highly Active Antiretroviral Therapy
Therapeutic Options New Options & New Challenges James A Zachary MD LSU Health Sciences Center HIV Outpatient Clinic 11 April 2005.
Pre Test !!!!!!. How many classes of HIV meds are currently available?
Antiretroviral drugs in UMMC Presenter: TE CHIN YEW Preceptor: KHOO SU LIN.
Antiretroviral Therapy: Pharmacology Cristina Gruta, PharmD, Asst. Clinical Professor of Clinical Pharmacy and FCM San Francisco AIDS Education and Training.
Practical Aspects of Antiretroviral Therapy
KITSO AIDS Training Program
Principles of HIV Therapy Simple is Better! Adeel A. Butt, MD Assistant Professor of Medicine and Infectious Diseases University of Pittsburgh Director,
Initiating Antiretroviral Therapy in Treatment-Naive Patients Charles B. Hicks, MD Associate Professor of Medicine, Division of Infectious Diseases and.
ANTIRETROVIRAL THERAPY Dr. Samuel Mwaniki (BPharm., MSc TID, UoN) University of Nairobi ISO 9001: Certified
Treatment of AIDS “Antiretroviral therapy & vaccines”
TMC125 Safety and Tolerability: 24-week Results of the Pooled DUET-1 and -2 Trials R Haubrich, M Schechter, S Walmsley, M Peeters, M Janssens, G De Smedt.
Hormonal Contraceptives – Considerations for Women with HIV and AIDS.
Combination Antiretroviral Therapy for HIV Infection by Ormrat Kampeerawipakorn.
ANTIRETROVIRAL RESISTANCE Jennifer Fulcher, MD, PhD.
Antivirals for HIV Yasir Waheed, PhD. Some HIV Facts HIV – the Human Immunodeficiency Virus is the retrovirus that causes AIDS HIV belongs to the retrovirus.
1 Side Effects of Anti-retroviral Therapy HAIVN Harvard Medical School AIDS Initiative in Vietnam.
Adverse Reactions & Antiretroviral Therapy Kirsten B. Balano, PharmD October 26, 2002.
1 Hepatic Toxicity in Patients Taking ARVs HAIVN Harvard Medical School AIDS Initiative in Vietnam.
KITSO AIDS Training Program
Antiretroviral Agents Pharma team 428 III- drug used for Rx of AIDS  AIDS are caused by HIV, and zidovudine was the first drug used (1987).  To understand.
HIV/ AIDS Answers to your questions. What is HIV HIV- Human Immunodeficiency Virus HIV- Human Immunodeficiency Virus The virus attacks the T-Cells in.
Introduction to ARV therapy
HIV opportunistic infections and HIV treatment Sabrina Assoumou, MD Section of Infectious Diseases.
PRINCIPLES OF ART IN TANZANIA
Issues Affecting ART Success: Adherence, ARV Toxicity, Drug Interactions Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents December.
Dosages and Side Effects of First-line ART
Improving Adherence With Simplified HAART Regimens Improving Clinical Outcomes in HIV Patients.
HIV:HCV Co-infection Landscape 21 of October, 09 Madrid,Spain GESIDA, Madrid.
26 YEARS OF HIV EPIDEMY 10 years HAART Dan Turner, MD, Tel-Aviv Sourasky Medical Center.
Elsevier Inc. items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Chapter 93 Antiviral Agents II: Drugs for HIV Infection and Related.
2009 Recommendations for Antiretroviral Therapy in Adults and Adolescents Summary of WHO Rapid Advice December 2009 Source: WHO HIV/AIDS Department.
BHIVA Clinical Audit Management of patients who switch therapy; re-audit of patients starting therapy from naïve.
When to Initiate ART in Adults and Adolescents (2009 WHO Guidelines) Target PopulationClinical conditionRecommendation Asymptomatic Individuals (including.
UK-CAB Jan05 BHIVA treatment guidelines UK-CAB - 28 Jan 2005 Simon Collins, HIV i-Base.
1 Review of Antiretroviral Therapy in Adults HAIVN Harvard Medical School AIDS Initiative in Vietnam.
Indications for Initiation of ARV Therapy in Children Age >1 Year Clinical Category CD4 + Cell Percentage Plasma HIV RNA Copy Number Recommendation AIDS.
WHO - PSM 14/7/2005 Principles for selection of medicines Dr Mary R. Couper Quality Assurance and Safety of Medicines WHO.
Guidelines for the use of antiretroviral agents in HIV infections in Taiwan, revised in 2002 by Infectious Diseases Society of the ROC and Taiwan AIDS.
TO EVALUATE EARLY ANTIVIRAL RESPONSE AND SAFETY OF A DUAL BOOSTED PROTEASE INHIBITORS REGIMEN INCLUDING LOPINAVIR/r (LPV) PLUS AMPRENAVIR (AMP) OR FORTOVASE.
1 Introduction to ARV Therapy HAIVN Harvard Medical School AIDS Initiative in Vietnam.
Current Concepts in HIV/AIDS A Pharmacy Perspective Carol Schneiderman, Pharm D Clinical Pharmacist, University of Arizona.
1 Second Line ART: Doses & Side Effects HAIVN Harvard Medical School AIDS Initiative in Vietnam.
Anti-viral Drugs.. Introduction The viral agents kill viruses by inhibiting their ability to replicate, but there are currently only about a dozen such.
Comparison of NNRTI vs PI/r  EFV vs LPV/r vs EFV + LPV/r –A5142 –Mexican Study  NVP vs ATV/r –ARTEN  EFV vs ATV/r –A5202.
Key1 ARV Treatment Guidelines for a Public Health Approach Product Selection for HIV Treatment Vincent Habiyambere February 2006.
Anti Retroviral Treatment Dr. Alap Mehta Senior Medical officer A.R.T. Centre.
Current and Future Trends in HIV Therapy Hail M. Al-Abdely Consultant, Infectious Diseases.
Why African Americans Must Understand and Participate in Clinical Trials and Vaccines Virginia A. Caine, M.D. Associate Professor of Medicine Division.
HIV Life Cycle Step 1: Fusion Step 2: Transcription reverse transcriptase Step 3: Integration Step 4: Cleavage Step 5: Packaging and Budding HIV.
Antiretroviral targets in the viral life cycle Viral Replication and Drug targets.
Second Line ARV: Doses & Side Effects HAIVN Harvard Medical School AIDS Initiative in Vietnam.
11 INTRODUCTION TO ANTIRETROVIRAL THERAPY (ART) IN CHILDREN: INITIATION AND MONITORING HAIVN Harvard Medical School AIDS Initiatives in Vietnam.
Side effects of antiretroviral drugs
 The Life Cycle of HIV  Step 1: Binding and Fusion  Drugs which affect this: › Fusion inhibitors › CCR5 Inhibitors
Copyright © 2016, 2013, 2010 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 94 Antiviral Agents II: Drugs for HIV Infection and.
1 Case Study Claire Biever, RN Morton Home Care Taunton, MA Linda Lebreux, RN, ACRN Medical Manager Infectious Disease Associates Taunton, MA Programs.
ART 101 Successful HIV treatment usually consists of at least three drugs from two different “classes” of ARV drugs There are now six classes of ARV drugs:
Answers to your questions
LPV-RTV versus LPV-RTV + ZDV-3TC in Treatment-Naïve MONARK Trial
Clinical and virologic follow-up in perinatally HIV-1-infected children and adolescents in Madrid with triple-class antiretroviral drug-resistant viruses 
School of Pharmacy, University of Nizwa
Antiretroviral therapy and its complications
Presentation transcript:

Rubin_MDS218_final1 Managing Adverse Effects of HAART David Rubin, MD Clinical Assistant Professor of Medicine Weill Cornell Medical College Medical Director, AIDS Center New York Hospital Queens

Rubin_MDS218_final2 Introduction n Despite the “revolution” of HAART transforming natural history of HIV infection, issues related to side effects confront patients and providers in “doing it right” n Focused management of these issues maximizes patients’ ultimate adherence to a given HAART regimen

Rubin_MDS218_final3 Understanding the Scope of the Problem n Broad treatment-related AEs —Lipodystrophy —Metabolic abnormalities —Bone disease n Drug-specific AEs —NRTIs —NNRTIs —PIs

Rubin_MDS218_final4 Importance of Adverse Effect Management n Increasing complexity of HAART —Increasing number of agents —Drug-drug interactions n Value of close monitoring to help patients ultimately tolerate difficult effects of certain agents —ie, ABC, NVP, EFV n Helping patients to tolerate the maximum number of agents preserves options for the future for that particular patient

Rubin_MDS218_final5 General Considerations n Many questions regarding effects of using antiretrovirals in current combinations remain unanswered, are there associations with —Cardiovascular disease —Diabetes mellitus —Chronic metabolic and morphologic changes ( a.k.a. Lipodystrophy)

Rubin_MDS218_final6 “Pro-Active” Approach to Initiating HAART n Important to discuss potential adverse effects with patient n Important to support the patient on starting meds, ie, inform patient on ways to contact you for “hand holding” n Adherence issues clearly are associated with this initial patient-provider interaction n Must frequently follow laboratory parameters, CBC, SMAC (chemistries including LFTs)

Rubin_MDS218_final7 Nucleoside Analogs (NRTIs) n Emerging data on “class” adverse rxns —Lactic acid level (lactic acidemia) —Rare lactic acidosis —Steatosis —Association of lactic acidemia with common NRTI side effects (?) —Theories of mitochondrial toxicity of agents explaining all AEs including lipodystrophy —Peripheral neuropathy: rapid/progressive Sx = discontinuation vs mild/intermittent

Rubin_MDS218_final8 Zidovudine (Retrovir, AZT) n Primary side effects: short term —Initial nausea —Initial headache —Ongoing nausea —Ongoing “dysphoria” n Primary side effects: long term —Anemia: usually noticed by 6 weeks —Leukopenia

Rubin_MDS218_final9 D-Drugs n d4T (Zerit ®, stavudine) —Peripheral neuropathy —Hepatitis —Pancreatitis n ddI (Videx ®, didanosine): new “EC” vs tablets, with better tolerability, issue for adherence —Pancreatitis —Peripheral neuropathy n ddC (Hivid ®, zalcitabine) —Peripheral neuropathy —Pancreatitis

Rubin_MDS218_final10 Abacavir Hypersensitivity n Initial discussion with patient —“the card” —Warning—not scaring, re: reintroduction n Description of syndrome —“Clinical diagnosis” only with varied presentation —Important to alert patient to contact you before stopping it, otherwise high likelihood of “losing it”

Rubin_MDS218_final11 Non-Nucleoside RTI (NNRTI) n Nevirapine —Rash l Management takes frequent monitoring to assess whether patient may continue or must stop, rash in up to 1/3 of patients l Keep in mind concern of “Stevens-Johnson” with desquamation of cutaneous and mucus membranes (<1%) —Hepatitis l May develop relatively quickly after start l Pay particular attention to co-infected patients with Hepatitis C in women

Rubin_MDS218_final12 NNRTIs n Efavirenz —CNS Side Effects l Dizziness: reason for QHS dosing l Vivid dreams l Depression –Think twice in patients with Hx of serious mental illness —Rash l Generally mild and self-limited n Delavirdine —Rash similar to NVP

Rubin_MDS218_final13 Protease Inhibitors (PIs) n General —GI side effects —Size and number of pills n But never forget: they first revolutionized HAART and currently clearly change progression rates to AIDS and death in the sickest patients, ie, CD4 <100

Rubin_MDS218_final14 Indinavir n Dosing —Crix q8 vs IDV/RTV —Hydration! —3 periods of food restriction vs none n Nephrolithiasis n “Retinoid Syndrome” n Hyperlipidemia (particularly with RTV) n Other renal issues n Hyperbilirubinemia

Rubin_MDS218_final15 Nelfinavir n Diarrhea! —Usual course: after initial dosing, presents in intermittent pattern —Best advice is to take after a substantial meal —Usually not accompanied with any other complaint —Responds to loperamide well, some use calcium carbonate

Rubin_MDS218_final16 Saquinavir n GI complaints: nausea, gas, bloating, cramps, and diarrhea —Symptomatic treatment —If occurs, becomes more tolerable over time —Amount of food prior to Rx n Size of pill issue —“GERD-type” symptoms may occur —Responds to Rx for GERD n Must be refrigerated

Rubin_MDS218_final17 Amprenavir n Size of pills —“GERD” and “mechanical” issues n GI Complaints — nausea, cramps, bloating, gas, and diarrhea n Rash (small but important)

Rubin_MDS218_final18 Ritonavir n Full dose is rarely used due to intolerable taste issues along with GI Sx n Combination with IDV, SQV, and LPV —Allows for BID dosing of all above with food n Hyperlipidemia & hyperglycemia n Must be refrigerated n Drug-drug interactions—many!

Rubin_MDS218_final19 Kaletra ® n First “fixed-dose” PI containing RTV, ie, LPV gets boosted to very high blood levels n GI side effects relatively mild, mostly “bloating and gas” n Taken with food n Must be refrigerated

Rubin_MDS218_final20 Conclusion n Side effect management clearly key element for maintaining high rate of adherence, thus frequent monitoring, including laboratory, is necessary n By maximizing support for patient to tolerate each potentially troublesome agent, you maximize the patient’s long-term options n Knowledge and “wisdom” play a large role in helping patients reach their goals as to managing AEs

Rubin_MDS218_final21 For more HIV-related resources, please visit