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Treatment of AIDS and HIV-Related Conditions: 2001 J Am Board Fam Pract: First Published As on 1 July 2001

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Treatment of AIDS and HIV-Related Conditions: 2001 J Am Board Fam Pract: First Published As on 1 July 2001 Current Report—HIV Treatment of AIDS and HIV-Related Conditions: 2001 J Am Board Fam Pract: first published as on 1 July 2001. Downloaded from Ronald H. Goldschmidt, MD, and Betty J. Dong, PharmD Managing human immunodeficiency virus (HIV) offer the best opportunity to provide comprehen- disease and the acquired immunodeficiency syn- sive care. drome (AIDS) has become more standardized yet This Current Report—HIV updates our annual more complex during the past year. Antiretroviral treatment guidelines.3 These recommendations treatment guidelines now represent a general con- (Table 1) are based on our experience at San Fran- sensus on basic treatment principles and options1 as cisco General Hospital, published guidelines, a re- benefits and risks of therapy have become more view of the medical literature, and experience evident. Clinical manifestations of HIV infection, gained from answering telephone calls to our Na- prognosis, and quality of life are clearly improved tional HIV Telephone Consultation Service for most patients receiving potent antiretroviral (Warmline). Because HIV management changes therapy, yet viral resistance and chronic and short- rapidly, clinicians are advised to refer to the excel- term drug toxicities remain major problems. The lent federal guidelines for the use of antiretroviral markedly decreased incidence of opportunistic in- agents in HIV-infected adults and adolescents1 and fections among treated patients has made unusual for prevention of opportunistic infections,4 which infections less common in daily HIV management. are updated frequently on the Internet (Table 2). The role of resistance assays in HIV care is still These and other federal guidelines are available at being assessed, but they offer great possibilities for http://www.hivatis.org. improving our ability to find satisfactory antiretro- http://www.jabfm.org/ viral regimens when others have failed. Finally, for the patient and the primary care clinician, the uni- Initiating Antiretroviral Therapy versal challenges of maintaining adherence to com- Concerns about development of antiretroviral drug plicated medication regimens and avoiding toxici- resistance and long-term antiretroviral drug toxic- ties and drug-drug interactions remain enormous ity have tempered the enthusiasm for early treat- obstacles. ment of asymptomatic persons. The strategy that Excellent HIV care requires applying the prin- promoted early aggressive therapy to maximally on 1 October 2021 by guest. Protected copyright. ciples of primary care, family care, and chronic care reduce viral load at all costs has given way to a more management with knowledge and experience in cautionary approach. Current recommendations1 managing HIV infection.2 Multidisciplinary team for initiating antiretroviral therapy include the fol- collaboration among primary care clinicians, phar- lowing concepts: initiating (and continuing) ther- macists, case workers, nurses, and AIDS experts can apy should always be based on the willingness, readiness, and capability of the HIV-infected per- son to adhere to a rigorous and presumably life- Submitted, revised, 8 May 2001. long treatment program; all patients with symptom- From the Family Practice Residency Program, San Fran- atic HIV disease should be offered antiretroviral cisco General Hospital (RHG, BJD), and the Departments ϩ of Family and Community Medicine (RHG, BJD) and Clin- therapy; asymptomatic persons with a CD4 lym- ical Pharmacy (BJD), University of California, San Fran- phocyte count less than 350/␮L or HIV RNA lev- cisco. Address reprint requests to Ronald H. Goldschmidt, MD, Family Practice Inpatient Service, San Francisco Gen- els greater than 30,000 copies/mL (bDNA assay) or eral Hospital, 1001 Potrero Ave, San Francisco, CA 94110. 55,000 copies/mL (RT-PCR assay) should be This article is also available at http://www.ucsf.edu/hivcntr. offered antiretroviral therapy; and patients Supported in part by the National HIV/AIDS Clinicians’ ϩ Consultation Center Grant No. 1 H4A HA 00038–01 with with CD4 cell counts fewer than 200/␮L should the AIDS Education and Training Centers, HIV/AIDS Bu- reau, Health Resources and Services Administration, De- receive antiretroviral therapy whenever possible. partment of Health and Human Services. Persons who wish to have antiretroviral therapy AIDS and HIV-Related Conditions: 2001 283 Table 1. Treatment Regimens for HIV Disease. General/Systemic p. 284 Oral cavity p. 296 Pulmonary p. 299 Skin/Mucocutaneous p. 292 Esophageal p. 297 Central Nervous System p. 303 J Am Board Fam Pract: first published as on 1 July 2001. Downloaded from Ophthalmologic p. 294 Gastrointestinal p. 298 System, Problem, and Drug Regimen Duration Adverse Effects/Drug Interactions Comments GENERAL/SYSTEMIC Antiretroviral (therapy) Combination antiretroviral (ARV) therapy is always recommended. Preferred regimens include two nucleoside reverse transcriptase inhibitors (NRTIs) along with either 1 or 2 protease inhibitors (PIs) or with the nonnucleoside reverse transcriptase inhibitor (nNRTI) efavirenz. Preferred NRTI combinations are zidovudine plus lamivudine or didanosine, and stavudine plus lamivudine or didanosine. Preferred PI therapy is with nelfinavir or indinavir, or with dual PI combination therapy with ritonavir plus indinavir, saquinavir, or lopinavir. Alternative NRTI combinations are didanosine plus lamivudine, and zidovudine plus zalcitabine. Alternative agents that can be used with 2 NRTIs include abacavir, amprenavir, delavirdine, nevirapine, ritonavir, saquinavir, and nelfinavir plus saquinavir. Cross-resistance among PIs is common, as is cross-resistance among nNRTIs. Zidovudine and stavudine should not be used in combination. Indinavir and saquinavir should not be used in combination. Other drug combinations might be necessary; resistance testing and expert consultation can be helpful. See text for further discussion Nucleoside reverse NRTI drug class effects: Nausea, vomiting; aminotransferase elevations (alanine transcriptase inhibitors transaminase [ALT], aspartate transaminase [AST]); lactic acidosis with hepatic (NRTIs) steatosis; mitochondrial toxicity; lipoatrophy Zidovudine (AZT, Until efficacy See NRTI drug class effects, above. Monitor for signs of zidovudine Retrovir) 200 mg po tid or wanes or Malaise, headache, insomnia, seizures, toxicity and reduce dosage if required. 300 mg po bid; lower toxicity occurs myalgias. Anemia, granulocytopenia, Transfusions or erythropoietin (if dosages (eg, 100 mg 3 thrombocytopenia; macrocytosis is an endogenous erythropoietin level Ͻ times daily) for patients expected effect of zidovudine therapy 500 IU/L) therapy can be used if unable to tolerate higher and requires no intervention. Toxic anemia (eg, hemoglobin Ͻ 8.0 g/dL) dosages and patients with myopathy (with elevated creatine occurs in patients who require renal failure or cirrhosis. phosphokinase [CPK]) with long-term zidovudine therapy. Decrease dosage Available as liquid use. Blue to black discoloration of nails or interrupt for absolute neutrophil formulation. Available also and skin in pigmented races count (ANC) Ͻ 500/␮L; consider as fixed-dose granulocyte colony-stimulating factor Drug interactions combinations: zidovudine (G-CSF). Transfusions and http://www.jabfm.org/ 300 mg plus lamivudine Careful monitoring required when used erythropoietin and G-CSF therapies 150 mg (Combivir) given with other myelosuppressive drugs (ie, are expensive; changing to alternate as one tablet po bid; and trimethoprim-sulfamethoxazole, NRTI preferred zidovudine 300 mg plus ganciclovir). Probenecid can increase lamivudine 150 mg plus levels of zidovudine. Acetaminophen High-dosage (1200 mg po qd) abacavir 300 mg (Trizivir), (Tylenol) administration does not zidovudine therapy can be considered given as one tablet po bid. increase zidovudine toxicity. Avoid for HIV dementia and Take with or without food concomitant use with ribavirin thrombocytopenia. Toxicity of high- dosage zidovudine can be substantial Didanosine (ddI, Videx) Until efficacy See NRTI drug class effects, above. Monitor for signs of neuropathy. Two on 1 October 2021 by guest. Protected copyright. 400 mg po qhs as 2 200- wanes or Pancreatitis; painful peripheral buffered tablets must be given per mg buffered tablets, or 200 toxicity occurs neuropathy (dosage related, reversible); dose to provide adequate buffer for mg po bid as 2 100-mg abdominal cramps, diarrhea related to absorption. Can be difficult to chew; chewable tablets or 250- antacid in formulation; rash; tablets do not dissolve readily in mg po bid powder for hyperglycemia; hyperuricemia; water, can be crushed manually or patients Ͼ 60 kg; 125 mg headache, insomnia, seizures; elevated given with apple juice (tablets) or 167 mg triglyceride and amylase levels; (powder) po bid for thrombocytopenia; retinal atrophy Administer didanosine on empty patients Ͻ 60 kg. Available stomach 2 hours apart from antacids, as enteric-coated capsules Drug interactions H2 antagonists, and drugs (eg, (Videx EC) given as 400- Avoid alcohol and other pancreatic ketoconazole, itraconazole, indinavir, mg EC capsule po qd (Ͼ toxins (eg, systemic pentamidine). Avoid lopinavir, ritonavir, tetracyclines, 60 kg) or 250-mg EC concomitant neurotoxic drugs (eg, delavirdine, quinolone antibiotics) capsule po qd (Ͻ 60 kg). zalcitabine, vinca alkaloids, oral whose absorption is impaired by Dosage reduction (ie, 200 ganciclovir). Decreases absorption of buffered products mg/d) in renal failure. drugs whose absorption is impaired
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