Home page  |  Help  |  Clear
English  |  French
 Search  |  Categories  |  Titles A-Z  |  Countries  |  Compare countries  |  Index  
Full TOC
Expand Document
Expand Chapter
Preferences

close this bookNational Guidelines for the Clinical Management of HIV/AIDS - Tanzania (NACP; 2005; 131 pages)
View the documentLIST OF ABBREVIATIONS
View the documentACKNOWLEDGEMENTS
View the documentFOREWORD
Open this folder and view contentsCHAPTER 1: INTRODUCTION
Open this folder and view contentsCHAPTER 2: ORGANIZATION OF HIV/AIDS CARE AND TREATMENT
Open this folder and view contentsCHAPTER 3: HIV/AIDS PREVENTION
Open this folder and view contentsCHAPTER 4: PROTECTIVE MEASURES AGAINST HIV TRANSMISSION
Open this folder and view contentsCHAPTER 5: LABORATORY TESTS IN HIV/AIDS
Open this folder and view contentsCHAPTER 6: HIV/AIDS AND PREGNANCY
Open this folder and view contentsCHAPTER 7: PEDIATRIC HIV/AIDS AND RELATED CONDITIONS
Open this folder and view contentsCHAPTER 8: COMMUNITY AND HOME BASED CARE FOR PEOPLE LIVING WITH HIV/AIDS (PLHA)
Open this folder and view contentsCHAPTER 9: COUNSELLING RELATED TO HIV-TESTING AND TREATMENT ADHERENCE
Open this folder and view contentsCHAPTER 10: MANAGEMENT OF COMMON SYMPTOMS AND OPPORTUNISTIC INFECTIONS IN HIV/AIDS
Open this folder and view contentsCHAPTER 11: MANAGEMENT OF MENTAL HEALTH PROBLEMS IN HIV/AIDS
close this folderCHAPTER 12: MANAGEMENT OF HIV INFECTED PATIENTS USING ANTIRETROVIRAL DRUGS
View the document12.1 Introduction
Open this folder and view contents12.2 Types of Antiretroviral drugs
Open this folder and view contents12.3 Treatment using ARV drugs in adults and adolescents
Open this folder and view contents12.4 Recommended ARV drugs in Tanzania
Open this folder and view contents12.5 Adherence to Antiretroviral Therapy
close this folder12.6 Changing of Antiretroviral Therapy
View the document12.6.1 Changing Antiretroviral therapy because of treatment failure
View the document12.6.2 Changing Antiretroviral therapy because of toxicity
View the document12.7 Second-Line ARV Regimen
Open this folder and view contents12.8 Monitoring Patients on ARV Therapy.
Open this folder and view contents12.9 Laboratory Monitoring of patients on second line drugs
Open this folder and view contents12.10 Treatment failure with second line regimen
View the document12.11 Contraindications (relative) for initiation of ART
View the document12.12 Discontinuation of ART
Open this folder and view contentsCHAPTER 13: ARV THERAPY IN INFANTS AND CHILDREN
Open this folder and view contentsCHAPTER 14: USE OF ARVS IN SPECIAL CIRCUMSTANCES
Open this folder and view contentsCHAPTER 15: HIV/AIDS AND NUTRITION
Open this folder and view contentsCHAPTER 16: MANAGEMENT OF ANTIRETROVIRAL MEDICINES
Open this folder and view contentsCHAPTER 17: CERTIFICATION OF HEALTHCARE FACILITIES AS CARE AND TREATMENT SITES
 

12.6.2 Changing Antiretroviral therapy because of toxicity

The general clinical recommendation is that when changing a patient’s regimen due to toxicity, only the toxic drug(s) should be replaced, if possible. The first line of the National ARV Program includes the following ARV drug combinations with some common toxicity switches.

Table 13: Common toxicity switches for First line drugs

First Line

Problem

Substitution

d4t + 3TC + NVP

Hypersensitivity due to NVP

d4T + 3TC + EFV*

d4t + 3TC + NVP or EFV*

Severe peripheral neuropathy due to d4T

AZT + 3TC + NVP or EFV*

AZT + 3TC + NVP or EFV*

Anemia due to AZT

d4T + 3TC + NVP or EFV*

d4T + 3TC + NVP or EFV*

Intolerant of NVP and EFV

D4T + 3TC + LPV/RTV**

* Only if patient is older than 3 years of age and a woman with no risk of pregnancy.
** Follow liver function tests (LFTs) closely.


Side effects or toxicities caused by ARVs can be classified into three broad categories:

First category: Symptoms are mild and transient which often require patient assurance that these symptoms are common and will decrease over time. ARV interruption is seldom indicated in this situation. These can be mild headaches, mild gastric upset, nausea, fatigue and the CNS disturbances seen with EFV.

Second category: Symptoms are somewhat more severe and often respond to some medical intervention. These include more severe gastric upset with nausea and vomiting, more severe headaches and mild peripheral neuropathy (not incapacitating or interfering with lifestyle). These symptoms can often be successfully treated with anti-emetics, anti-diarrhoea medicines, analgesics, neuroleptics (amitriptylene) and other medicines. ARV interruption is usually not indicated in this situation and often symptomatic treatment is only temporary. The mild rash associated with NVP will be considered under a separate paragraph below but can often be treated with medical intervention.

Third category: Severe symptoms in which an ARV drug must be stopped and replaced by an alternative drug. These include anemia (hemoglobin < 7.5 gm/dl or a falling haemoglobin, often that drops by 2 gm/dl) as can occur with the use of AZT. Severe symptoms noted in the first two categories can sometimes lead to the stopping of ARV due to severe toxicities such as nausea with severe discomfort and minimal intake for 3 or more days, vomiting all intake in 24 hours or dehydration due to vomiting, severe headache not responsive to non-narcotic analgesics, or fatigue reducing activity by more than 50%. In these situations, one or more ARVs are replaced by another.

This also includes the hypersensitivity reaction to NVP which can include a severe rash or liver function test (LFT) elevations to grade III or > 5 times the upper limit of normal range.

NVP hypersensitivity reactions

NVP hypersensitivity reactions can manifest as a rash and/or elevated LFTs. The rash can occur in up to 20 % of patients and usually occurs in the first 6-8 weeks of therapy. NVP will be initiated at a lower dose for the first 2 weeks when only one NVP dose is given per day for 14 days. If there are no clinical signs or symptoms of a NVP hypersensitivity or allergy, the LFT (ALAT) will be checked and the NVP dose will be escalated to 2 doses per day starting at the week 2 visit.

There are commonly two levels of severity in NVP-induced rashes.

Mild NVP hypersensitivity reaction:

A mild rash is defined as erythema, urticaria, intact skin, no blistering or sloughing of skin or desquamation, no involvement of mucous membranes, no angioedema, and no systemic signs (body aches, arthralgias, myalgias, fevers, lymphadenopathy or significantly elevated LFTs). If a mild drug-reaction type rash occurs, patients will continue treatment with caution and careful monitoring. LFTs that are less than grade III (<5 times the upper limit of normal) can usually be followed to resolution. This rash will be treated with patient assurance, antihistamines and close follow up until resolved. NVP dose escalation will be deferred for up to one week until symptoms resolve. If symptoms worsen, this may indicate that the patient has severe hypersensitivity reaction and NVP will need to be stopped immediately and other medical interventions considered, as noted in the next paragraph.

Severe NVP hypersensitivity reaction (Stevens-Johnson Syndrome, SJS):

A severe rash is defined as severe erythema, urticaria, desquamation of skin (moist), skin blistering, sloughing of skin, exfoliative dermatitis, erythema multiforme (when severe and involving the mucous membranes is known as SJS), anaphylaxis, involvement of mucous membranes, angioedema, cracked/fissured lips, or systemic signs (body aches, arthalgias, myalgias, fevers, lymphadenopathy or significantly elevated LFTs). If a severe drug-reaction type rash occurs, patients will discontinue NVP treatment, begin high dose prednisolone, antihistamines, analgesics, and be admitted to the hospital for IV fluids and careful monitoring. LFTs can be grade III (>5 times the upper limit of normal) or higher. NVP will be stopped immediately and not re-introduced. All ARVs will be stopped. Once the patient recovers, 3 ARV drugs will be started that do not include NVP. The remaining 2 ARVs will be paired with a replacement ARV such as EFV, if not contraindicated.

ABC (Abacavir) hypersensitivity

ABC hypersensitivity occurs in 3-5% of patients and can be fatal. Hypersensitivity symptoms include: flu symptoms, shortness of breath, cough, fever, achiness, generally ill feeling, fatigue/tiredness, swelling, abdominal pain, diarrhea, nausea, muscle or joint aches, numbness, sore throat or rash. ABC will be stopped immediately and not re-started if this occurs. If there is a history of ABC hypersensitivity, then ABC is contraindicated.

EFV Side effects

EFV can cause CNS side effects such as vivid dreams, nightmares, vertigo, or confusion. These symptoms are often mild and transient. Patients may benefit from assurance that these symptoms are common and will decrease over time.

D4T Side effects

Peripheral Neuropathy is a common side effect and occurrence of lactic acidosis has been reported and need to be carefully monitored.

to previous sectionto next section

Please provide your feedback English  |  French