HEPP Report: Infectious Diseases in Corrections, Vol. 6 No. 6 HIV & Hepatitis Education Prison Project
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University of Rhode Island DigitalCommons@URI Infectious Diseases in Corrections Report (IDCR) 2003 HEPP Report: Infectious Diseases in Corrections, Vol. 6 No. 6 HIV & Hepatitis Education Prison Project Follow this and additional works at: http://digitalcommons.uri.edu/idcr Recommended Citation HIV & Hepatitis Education Prison Project, "HEPP Report: Infectious Diseases in Corrections, Vol. 6 No. 6" (2003). Infectious Diseases in Corrections Report (IDCR). Paper 46. http://digitalcommons.uri.edu/idcr/46 This Article is brought to you for free and open access by DigitalCommons@URI. It has been accepted for inclusion in Infectious Diseases in Corrections Report (IDCR) by an authorized administrator of DigitalCommons@URI. For more information, please contact [email protected]. HIV & HEPATITIS EDUCATION PRISON HEPJune 2003 Vol. 6, Issue 6 P REPORT PROJECT Infectious Diseases in Corrections SPONSOREDBYTHEBROWNMEDICALSCHOOLOFFICEOFCONTINUINGMEDICALEDUCATION. ABOUT HEPP Long-Term Toxicities Associated with HIV and HEPP Report, a forum for Antiretroviral Therapy correctional problem solving, targets correctional physicians, nurses, By Peter J. Piliero, M.D.*, Associate Professor of Medicine, Albany Medical College administrators, outreach workers, and Soon after the introduction of the first antiretroviraldine (3TC) have also been associated with pan- case managers. Published monthly (ARV) agent, zidovudine (AZT), drug-related toxi-creatitis. There may be an added potential for pan- and distributed by email and fax, cities became recognized and well-characterized.creatitis when using combinations of these nucle- HEPP Report provides up-to-the Things have since become more complicated;oside reverse transcriptase inhibitors (NRTIs). moment information HIV/AIDS, there are now 17 ARV agents in four distinct class-Importantly, the concomitant use of alcohol hepatitis, and other infectious es. This has led to both decreased morbidity andincreases the risk of pancreatitis. In cases of acute diseases, as well as efficient ways mortality from HIV infection due to immune recon-pancreatitis, temporary interruption of ART is rec- to administer treatment in the correctional environment. Continuing stitution and viral suppression, and increasingommended. Subsequent resumption should avoid Medical Education credits are recognition of both acute and long-term toxicitiesthe likely causative agents the patient was taking provided by the Brown University of ARV therapy (ART). Most clinicians agree thatat the time he or she developed pancreatitis. Office of Continuing Medical the benefits of ART generally outweigh the risk; however, patients who experience significant sidePeripheral neuropathy Education. HEPP Report is Peripheral neuropathy usually occurs after pro- effects sometimes disagree with this. This can distributed to all members of the longed use of NRTIs.4This complication is most Society of Correctional Physicians lead to patient non-adherence or refusal to take often associated with the use of the "d-drugs" - (SCP) within the SCP publication, any ART at all for fear of toxicity. Drug toxicities zalcitabine (ddC), stavudine (d4T), and didano- CorrDocs (www.corrdocs.org). may have both acute and long-term implications to sine (ddI) (in decreasing order of likelihood). The the health of HIV-infected persons. combined use of two of these drugs has been CO-CHIEF EDITORS This report reviews common acute and long-termassociated with an even higher incidence of neu- Joseph Bick, M.D.toxicities of ART. Drug toxicities can be class-spe-ropathy. Recognizing neuropathic symptoms early Director, HIV Treatment Services, California Medical Facility, cific or ARV-agent specific. Having an under-on, and reducing or interrupting the offending California Department of Corrections standing of these complications allows cliniciansagent(s) usually leads to symptom resolution. If to anticipate potential toxicities, and to communi-patients are maintained on these drugs, progres- Anne S. De Groot, M.D.cate about them with their patients. Clinicianssive and often permanent neuropathy requiring Director, TB/HIV Research Lab, Brown Medical School should inform patients considering ART what com-narcotic analgesia may ensue. plications they may experience, how to recognize Lactic acidosis DEPUTY EDITORS these side effects, and what they should do about Lactic acidosis syndrome (LAS) was first reported Frederick L. Altice, M.D.them. This proactive approach is likely to lead to a in the early 1990s in association with zidovudine Director, HIV in Prisons Program, more trusting relationship and improved adher- (AZT) use, predominantly in obese African- Yale University AIDS Program ence.1 American women. In recent years, the greatest David P. Paar, M.D. Director, AIDS Care and Clinical Mitochondrial Toxicity association has been with the use of stavudine Research Program, In recent years, mitochondrial toxicity has been(d4T) with or without didanosine (ddI). The nucle- University of Texas, Medical Branch recognized as one of the most serious potentialoside and nucleotide analogues inhibit mitochon- side effects of ART.2Mitochondria are the energy-drial DNA production, which leads to an increased Stephen Tabet, M.D., M.P.H University of Washington and Northwest producing factories of our bodies; when mitochon-breakdown of fatty acids into lactic acid. Inhibition AIDS Education and Training Center drial production is decreased by inhibition of theis greatest for the "d-drugs" but also occurs with cellular DNA polymerase gamma, end-organ toxi-the other NRTIs.5 city can occur. Mitochondrial toxicity is associated SUPPORTERS Patients with LAS generally present with vague with the use of the nucleoside and nucleotide HEPP Report is grateful for constitutional complaints including fatigue, reverse transcriptase inhibitors, and may lead to a the support of the following malaise, abdominal pain, and nausea and vomit- companies through unrestricted number of clinical problems. These include pan- Continued on page 2 educational grants: creatitis, peripheral neuropathy, and increased production of lactic acid. Major Support:Abbott Laboratories, WHAT’S INSIDE Agouron Pharmaceuticals, and Pancreatitis Roche Pharmaceuticals. Pancreatitis can be an acute complication of ART, SARS Update pg 4 Sustaining:Boehringer Ingelheim even though it may occur after years of stable HIV 101 pg 5 Pharmaceuticals, Gilead Sciences, 3 Ask the Expert pg 6 Inc., GlaxoSmithKline, Merck & Co. treatment.This potential fatal complication has and Schering-Plough. been linked predominantly to the use of didano- Self-Assessment Test pg 9 sine (ddI); however, stavudine (d4T) and lamivu- Brown Medical School Providence, RI 02912 401.277.3651 fax: 401.277.3656 www.hivcorrections.org If you have any problems with this fax transmission please call 800.748.4336 or e-mail us at [email protected] June 2003 Volume 6, Issue 6 visit HEPP Report online at www.hivcorrections.org 2 Long-Term Toxicities... use of protease inhibitors (PIs). SubsequentThe pathogenesis of fat maldistribution (continued from page 1) cohort studies have confirmed this associa-remains elusive. Retrospective cohort studies ing. Over the course of several weeks, thesetion, which is largely due to acquired insulinhave defined characteristics associated with 10 patients can develop tachypnea, pancreatitis,resistance.Patients with HCV co-infectiondevelopment of lipodystrophy: these include and/or hepatitis in the setting of progressiveappear to be at greater risk of developing thisan age >40 years, nadir CD4 cell count, acidemia. If unrecognized, death may occur.complication. Caucasian race, and antiretroviral use. More recently, a prospective study of ARV-naïve The clinician considering this diagnosis earlyDiagnosis is usually performed through peri- patients initiating therapy showed an associa- on in the setting of vague complaints shouldodic fasting glucose determinations or by a tion between development of lipoatrophy and obtain an arterial or venous lactate level. Atwo-hour oral glucose tolerance test. use of a stavudine-containing regimen, and mildly elevated level (2-5 mmol/L) is diagnos-Glycosylated hemoglobin levels are usually lipohypertrophy and the use of a PI-contain- tic of symptomatic hyperlactatemia, whereasnormal even in the setting of insulin resis- ing regimen. These investigators also defined a level >5 mmol/L in conjunction with atance. Treatment depends on the severity of a pattern to changes in body morphology reduced arterial pH confirms the diagnosis ofthe hyperglycemia, with mild cases respond- occurring after initiation of therapy. LAS. In both situations, interruption of ARTing to dietary intervention and exercise, mod- Specifically, patients gained fat and lean until resolution is necessary. Subsequenterate cases responding to insulin-sensitizing mass during the first 24 weeks of therapy, fol- therapy should, when possible, avoid thoseagents such as the glitazones, and severe lowed by progressive loss of extremity fat drugs most associated with LAS. cases responding to insulin therapy. while preserving gained central abdominal fat Modifying the regimen by replacing the PI 13 Metabolic Complications over the next 72 weeks of therapy. Various metabolic complications associatedwith a non-PI agent may also be successful. No definitive treatment for fat maldistribution with HIV have now been recognized. TheseDisorders of Bone include dyslipidemia, insulin resistance/dia- exists, though different approaches have Metabolism