1 / 29

Prescribing ARVs

Prescription and Use of Paediatric Antiretroviral Drugs (ARVs) for the Treatment of HIV in Children. Prescribing ARVs. Key Questions: How do we select the appropriate regimen? How do we select the most effective ARV formulations?

pooky
Download Presentation

Prescribing ARVs

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Prescription and Use of Paediatric Antiretroviral Drugs (ARVs) for the Treatment of HIV in Children

  2. Prescribing ARVs • Key Questions: • How do we select the appropriate regimen? • How do we select the most effective ARV formulations? • How do we prescribe appropriate doses of each formulation based on the child’s weight?

  3. Three Steps to Prescribing Ped ARVs • Once a child has been identified as eligible for • ART and prepared to initiate treatment, there • are three steps to prescribing ARVs: • Identify the proper regimen to prescribe • based on National Guidelines and clinical condition of the child • 2. Select which ARV formulations to use • based on the regimen selected • Use the Paediatric ARV Dosing Chart to prescribe the proper amount of each formulation • based on the child’s weight

  4. Review of Regularly Used ARVs

  5. Step 1: Identify the right regimen Select the appropriate regimen based on the national ART guidelines: AZT based regimen should always be used to initiate children on 1st line, unless the child is anemic

  6. Step 2: Choose the right formulations • Pediatric ARVs are available in three kinds of formulations: • Oral suspensions • i.e. AZT syrup • 2. Single drug tablets • i.e. 3TC 150mg • Fixed-dose combination tablets • i.e. Triomune Baby • (d4T 6mg + 3TC 30mg + NVP 50mg)

  7. Step 2: Choose the right formulations Many different products are available to choose from…

  8. Step 2: Choose the right formulations • However, fixed-dose combinations should always be used when possible due to their many advantages over oral suspensions and single tabs: • Easier to dose, as you do not have to give instructions for multiple drugs • Better control in administration than oral solutions • More versatile – can be crushed, dispersed in food or water, or swallowed as a tablet • More neutral taste • Lower tablet burden/volumes • Easier to check adherence • Easier to transport/store with no need for refrigeration • Easier to order due to reduced number of formulations

  9. Step 2: Choose the right formulations Fixed-dose combinations can and should be used to build every recommended regimen:

  10. Fixed-dose combination tablets can be split, crushed, and most of them dispersed in water: X X

  11. Step 2: Choosing the right formulation Fixed-dose combination tablets can be split, crushed, and most of them dispersed in water: X X

  12. Exercise 1 – Administering FDC tablets • Take three fixed dose combination tablets: • Split the first one in half • Crush the second with a spoon • Put the third in a cup and add a few MLs of water—watch it dissolve in the water Which was difficult to do? Which is easiest to teach to a mother of an HIV+ child?

  13. Step 2: Choose the right formulation When using fixed-dose combinations, you only require the following pediatric formulations at your facility: * Will also need NVP 200mg, but that is also used for adults so should be readily available

  14. Step 3: Prescribe the right dose • The first step in dosing ARVs for children is determining the weight of the child—doses need to be increased as the child grows • There are 6 major weight ranges to use when dosing: • 3 – 5.9kg • 6 – 9.9kg • 10 – 13.9kg • 14 – 19.9kg • 20 – 24.9kg • 25kg and above You must weigh a child each time he/she comes to the clinic to check if he/she has reached the next weight range

  15. Step 3: Prescribe the right dose • Dosing of fixed-dose combinations is harmonized across drug types… The number of tabletsincluded in the table aboveisgiventwicedaily

  16. Step 3: Prescribe the right dose • Dosing aide provides number of tablet to give for each formulation (including CTX) across all weight ranges:

  17. Exercise 2:Use your Paediatric ARV Dosing Chart to answer the following about dosing FDCs: • For a 9kg child on the regimen AZT + 3TC + NVP: • Which formulation would you use for this child? • Triple FDC • b. What is the average daily dose of this formulation? • 1.5 BD • c. How many tablets should you dispense for 30 days? • 90 tablets

  18. Exercise 2: Dosing Ped FDCs (continued) 2. For a 16kg child on the regimen ABC + 3TC + EFV: • Which formulations would you use for this child? Dual FD of ABC + 3TC, and single dose tablet of EFV b. What is the average daily dose of these formulations? ABC/3TC 2.5 BD, 300mg of EFV c. How many tablets of each formulation should you dispense for 30 days? ABC + 3TC = 150 tablets For EFV, first need to decide on the best formulation for the patient. Is there a 300 mg tablet? NO.

  19. Exercise 3 – Dosing syrups vs FDCs You have a patient who weighs 5 kg. You prescribe a regimen of AZT/3TC/NVP. 1st: Calculate the AM and PM dose if you were to use syrups. What is the total volume needed for a 30-day supply? AZT = 360 ml, 3TC = 180 ml , NVP = 300 ml 2nd: Calculate the AM and PM dose if you were to use FDCs. What is the total number of tablets needed for a 30-day supply? FDC = 60 tablets

  20. We need to consider what the patient will have to go home with…

  21. Using FDCs for lead-in NVP dosing • Current recommendation for any patient initiating NVP-based ART for the first time is to dose the NVP once daily for the first two weeks to reduce risk of associated rash • During 2 week lead in period, children should get the appropriate triple FDC as the AM dose, and the equivalent dual FDC for the PM dose

  22. Exercise 4 – Lead-in dosing with FDCs 4 year old child Weight 12.5kg Eligible for ART AZT/3TC/NVP 60/30/50mg Formulation? 2 am / 2 pm Dose? Lead-in? 28 tabs of triple FDC, 28 tabs of dual FDC 120 tabs of triple FDC until weight increases to 15kg 120 tabs of triple FDC Initiate lead-in for 2 weeks Initiate full ART Follow up

  23. Case Study Practice • Let’s examine a few real cases and correctly determine: • What regimen should they be given? • What formulations should you use? • How much would you prescribe of each formulation?

  24. Case 1 Osofia is 3 month old and weighs 5 kg. She was given single dose NVP for PMTCT but went on to get HIV infected. Currently you don’t have kaletra syrup at your facility. Initiate the patient on treatment in the recommended way. • What regimen should she be given? AZT/3TC/NVP • What formulations should you use? Triple FDC of AZT/3TC/NVP and Duo fixed dose AZT/3TC • How much would you prescribe of each formulation? Triple FDC AZT/3TC/NVP-1 od and AZT/3TC 1 od • If you are giving them a 14-day supply, how many tablets should you give them of each formulation? AZT/3TC/NVP 14 tablet and AZT/3TC -14 tablets

  25. Case 2 IBU is a 6 month old infant who is HIV positive. He received NVP syrup for prophylaxis. He is not anemic and the weight is 6 kg. You have all the drugs available in the facility. • What regimen should they be given? AZT/3TC/Kaletra • What formulations should you use? FDC- AZT/3TC and Syrup for kaletra • How much would you prescribe of each formulation? AZT/3TC- 1.5 BD and Kaletra 1.5 mlsBD • If you are giving them a 30-day supply, how many tablets should you give them of each formulation? AZT/3TC 90 tablets and Kaletra 90mls for 30 days

  26. Case 3Mary is 4 years old and weighs 15 kg. She was diagnosed with HIV. She is anemic and you don’t have abacavir in your facility. • What criteria would you use to determine if Mary is eligible for ARVs? CD4 %- less than 25% or CD count <750 or WHO clinical stage 3 or 4 If she is eligible for ARVs • What regimen should she be given? D4T/3TC/NVP • What formulations should you use? Triple FDC of D4T/3TC/NVP babyand Duo FDC D4T/3TC baby • How much would you prescribe of each formulation? D4T/3TC/NVP 2.5 A.M. and D4T/3TC 2.5 P.M. • If you are giving her a 14-day supply, how many tablets should you give her of each formulation? D4T/3TC/NVP 35 tablets and D4T/3TC 35 tablets • If she comes back for after 14 days as she has tolerated the drugs what formulation would you give, what dose and how many tablets would you dispense for 30 days? D4T/3TC/NVP baby , 2.5 BD and 150 mg

  27. Case 4 Aki is a 7 year old HIV positive boy. He is anemic and is eligible to start ARV’s. You have abacavirin you facility. He is 18 kg. • What regimen should they be given? ABC/3TC/NVP or ABC/3TC/EFV • What formulations should you use? Duo FDC for ABC/3TC and single tablets NVP or Duo FDC ABC/3TC and single tablet EFV • How much would you prescribe of each formulation? ABC/3TC 2.5 BD and Tab NVP 1 in morning and 0.5 in Evening Or ABC/3TC 2.5 BD and Tab EFV(600mg) 0.5 mg od • If you are giving them a 30-day supply, how many tablets should you give them of each formulation? ABC/3TC 150 tablets and NVP 45 tablets Or ABC/3TC 150 tablets and EFV 15 tablets

  28. Case 5 Popo is a 9 year old boy who is HIV+. He is not on ARVs and was diagnosed with TB. His weight is 21kg. He is eligible to start ARVs. • When would you start him on ARVs 2-8 weeks after initiation of anti TB treatment • What regimen should they be given? AZT/3TC/EFV • What formulations should you use? Dou FDC AZT/3TC and single tablet EFV • How much would you prescribe of each formulation? AZT/3TC 3BD and EFV (600mg) 0.5 od • If you are giving them a 30-day supply, how many tablets should you give them of each formulation? AZT/3TC 180 tablets and EFV(600mg) 15 tablets

  29. Summary • Use the national ART guidelines to select which regimen to use • Always check for anemia to determine if AZT is acceptable • When selecting formulations, always use fixed-dose combinations where possible • Easier to dose and better for the patient • Always take the child’s weight, and use the Ped ARV dosing chart to determine how much to prescribe of each formulation

More Related