Guidelines to Antiretroviral Drug Therapy in Kenya: CHAPTER TWO: MONITORING AND CHANGING THERAPY: 2.8 Potential options for changing therapy*

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	Guidelines to Antiretroviral Drug Therapy in Kenya (WHO; 2001; 78 pages)
		FOREWORD
		ACKNOWLEDGMENT
		CHAPTER ONE: INITIATING ANTIRETROVIRAL THERAPY
			1.1 Introduction
			1.2 Guidelines to making a diagnosis of HIV infection
			1.3 Laboratory Diagnosis of HIV infection
			1.4 Goals of therapy
			1.5 When to start therapy
			1.6 Risks and benefits of delayed initiation of therapy and of early therapy in the Asymptomatic HIV-Infected Patient
			1.7 Antiretroviral profile
			1.8 What drug combination to start with?
		CHAPTER TWO: MONITORING AND CHANGING THERAPY
			2.1 Surrogate markers
			2.2 Resistance testing
			2.3 How often should CD4 Cell Count and Viral Load be performed (Frequency)
			2.4 Treatment failure
			2.5 Reasons for non-adherence
			2.6 Considerations for changing a failing regimen
			2.7 Guidelines for changing an antiretroviral regimen for suspected drug failure
			2.8 Potential options for changing therapy*
		CHAPTER THREE: PHARMACOTHERAPEUTICS OF ARVS
			3.1 Characteristics of available antiretroviral drugs
			3.2 Pharmacokinetic properties of Antiretrovirals
		CHAPTER FOUR: GUIDELINES FOR THE USE OF ANTIRETROVIRAL DRUGS IN PAEDIATRIC HIV INFECTION
			4.1 Overview
			4.2 Diagnosis of HIV infection in children
			4.3 When to initiate treatment
			4.4 Initiation of treatment
			4.5 Agents to choose for initial treatment
			4.6 Dosages for paediatric formulations
			4.8 Monitoring
			4.9 When to change therapy
		CHAPTER FIVE: MANAGEMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTED PREGNANT WOMEN AND PREVENTION OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV
			5.1 Overview
			5.2 Factors affecting mother to child transmission
			5.3 Outline antenatal, intrapartum postpartum and postnatal care
			5.4 Antiretroviral Therapy to prevent MTCT
		CHAPTER SIX: SPECIAL CONSIDERATIONS
			6.1 Acute retroviral syndrome (ARVS)
			6.2 ARV drugs and the treatment of Tuberculosis
			6.3 Immune recovery syndrome
		CHAPTER SEVEN: WHEN TO STOP TREATMENT (INTERRUPTIONS)
			7.1 Structured treatment interruptions (STI's)
			7.2 Non structured treatment interruption
		CHAPTER EIGHT: GUIDELINES FOR POST EXPOSURE PROPHYLAXIS
			8.1 Treatment of exposure sites
			8.2 Timing of post - HIV exposure prophylaxis initiation
			8.3 Assessment of exposure risk
			8.4 Post - HIV exposure prophylaxis
			8.5 Recommended HIV serology after exposure
			8.6 Management of health care workers with accidental exposure to HIV infection
			8.7 Management of hospital staff with sharp injury or exposure to blood and body fluids
			8.8 Management of non occupational exposure to HIV infection
			8.9 Management of non-sexual and non occupational Exposures to HIV
		CHAPTER NINE: ACCESS TO DRUGS IN KENYA
		APPENDICES
			I. Drug to drug interactions
			II. Drug to drug interactions (continued)
			III. Drug Interactions Between Antiretrovirals and Other Drugs
			IV. Nucleoside Reverse Transcriptase Inhibitors (NRTIS)
			V. Drug Interactions: Protease Inhibitors
			VI. Drug Interactions: Protease Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors - Cont.
			VII. Drug That Should Not be Used With Antiretrovirals
			VIII. Drugs that should not be used with Protease Inhibitors Antiretrovirals
			IX. HIV-related drugs with overlapping toxicities
			X. Anti-retroviral therapy for preventing MTCT
		BACK COVER

2.8 Potential options for changing therapy*

Reasons for change	Change
Toxicity or intolerance HIV RNA suppressed below target	Change the offending drug (if discernible)
HIV RNA suppressed but still above target And fewer than 8-16 weeks with therapy.	Change offending drug if discernible
HIV RNA above target, more than 8-16 weeks	Change entire regimen
Difficulty with adherence HIV RNA suppressed below target, but adherence problems present	Change to simplified regimen with equal potency; substitute single drug if known
HIV RNA above target, more than 8-16 weeks with therapy.	Change to simplified regimen with equal potency substitute single drug if known.
HIV RNA above target, more than 8-16 weeks with therapy or prior successes.	Change entire regimen
Virologic failure adherence, Failure to reach target viral load within adherence 8-16, weeks of therapy	Continue current regimen, assess consider intensification.
Failure to reach target viral load within 24-36 weeks of therapy	Change entire regime
Prior success but now confirmed drug faiture.	Change entire regime

Possible Regimens for patients who have failed initial Antiretroviral Therapy:

Possible Second line Regimens for Treatment Failure

• Following AZT/3TC/NFV

- d4T/ddl/EFZ or
- d4T/ddl/LPV or
- d4T/ddl/IDV

• Following AZT/3TC/EFZ(or NVP)

- d4T/ddl/NFV or
- d4T/ddl/LPV,

• Following AZT/3TC/NFV

- d4T/ddl/EFZ or
- d4T/ddl/LPV or
- d4T/ddl/IDV

Prior Regimen		New Regimen (Not listed in priority order)
2 NRTIs +		2 new NRTIs
	Nelfinavir	RTV; IDV; or SQV + RTV; or NNRTI + RTV; or NNRTI ID**
	Ritonavir	SQV + RTV**; NFV + NNRTI; or NFV + SQV
	Indinavir	SQV + RTV; NFV + SQV
	Saquinavir	RTV + SQV; OR NNRTI + IDV RTV + IDV
2 NRTIs + NNRTI		2 new NRTIs + a protease inhibitor
2 NRTIs		2 new NRTIs + a protease inhibitor
		2 new NRTIs + RTV + SQV
		1 new NRTI + 1 NNRTI + a protease inhibitor
		2 protease inhibitors + NNRTI
1 NRTI		2 new NRTIs + a protease inhibitor
		2 new NRTIs + NNRTI
		1 new NRTI + 1 NNRTI + a protease inhibitor

These alternative combinations are still being studied in clinical trials and will be amended as more information is published.

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