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Side Effects of Anti-retroviral Therapy

Side Effects of Anti-retroviral Therapy. HAIVN Harvard Medical School AIDS Initiative in Vietnam. Learning Objectives. By the end of this session, participants will be able to: List the side effects of ARVs used in Vietnam Recognize the side effects when caring for patients

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Side Effects of Anti-retroviral Therapy

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  1. Side Effects of Anti-retroviral Therapy HAIVN Harvard Medical School AIDS Initiative in Vietnam

  2. Learning Objectives By the end of this session, participants will be able to: • List the side effects of ARVs used in Vietnam • Recognize the side effects when caring for patients • Educate patients to recognize and monitor side effects of ARVs

  3. Overview:Side Effects of ARVs (1) Side Effects of ARVs: • Light side effects: occur in first weeks of ARV commence, and improve gradually (nausea, vomit) • In more severer cases, may required: • Symptom treatment or • Change medications • Some side effects are related to: • Dosage and/or • Interactive with other medications

  4. Overview:Side Effects of ARVs (2) Patients should be carefully educated so that they can: • Recognize side effects of medications • Inform health workers to have timely management • Better adherence

  5. ARV Drugs Currently Available in Vietnam

  6. Combination Pills Availablein Vietnam

  7. Side Effects of First-line ARVs

  8. Side Effects of d4T

  9. Peripheral Neuropathy: Symptoms • This is a common side effect of d4T • Symptoms: • Pain or tingling in hands and feet • Stocking and glove distribution • Symmetrical

  10. Peripheral Neuropathy: How to Manage? Nurses can: • Ask patients on each visit about the symptoms • Educate patients: • Loose shoes/sandals • Light bedding • Walk a little, not a lot! • Cool water soaks • Try Ibuprofen for pain

  11. Lipodystrophy (1) • Dorsocervical enlargement (humpback)

  12. Lipodystrophy (2) • Abdominal (visceral) adiposity

  13. Lipodystrophy (3) sunken cheeks prominent veins

  14. Pancreatitis: Symptoms • This is a serious side effect of d4T • Symptoms: • Abdominal pain • Nausea, and vomiting • More common among patients who use alcohol

  15. Pancreatitis: Management • Must STOP the medication • Patients should come to clinic • May need to be hospitalized

  16. Side Effects of AZT

  17. Nausea and Vomiting: Symptoms • Very common at start of therapy • Often improves with time: • Provide reassurance

  18. Nausea and Vomiting: Management (1) In minor cases, educate patients to: • Take the AZT with a little food • Eat small frequent meals • Avoid spicy or fried foods • Replace fluids (tea, broth) • Anti-nausea medications as needed

  19. Nausea and Vomiting: Management (2) Educate patients to go to the clinic or hospital if: • There is blood in the vomit • Pain in your stomach • Fever • Vomiting persists more than 1 day • Be thirsty, but can not eat or drink properly

  20. Headache (1) • Usually declines in frequency 2-4 weeks after beginning AZT • Patient education in minor cases: • Try paracetamol • Rest in quiet, dark room • Cool cloth over eyes • Avoid caffiene (coffee, strong tea, soda)

  21. Headache (2) • Educate patients to go to clinic if: • Vision changes • Paracetamol doesn’t relieve the pain • Headaches are very severe and frequent • Difficulty with walking or balance • Confusion

  22. Serious Side Effects (1) Bone marrow suppression: • Anemia • Severe reduction in red blood cells • Fatigue, shortness of breath • Neutropenia: • Low white blood count • Diminished ability to fight infections

  23. Serious Side Effects: Management • Closely monitor patients to recognize symptoms of serious side effects • May need to swap for D4T or TDF

  24. Side Effects of Nevirapine (NVP)

  25. Rash: Symptoms • Rash caused by NVP usually appears 2-6 first wks of treatment, but could be later

  26. Mild Rash (1)

  27. Mild Rash (2)

  28. Mild Rash: Management Educate patients: • Note when rashes developed and report to nurses and doctors • Avoid soaps, shower cream • Do not taking bath with hot water • Avoid direct sunlight • Use Antihistamines tablet or cream • Come to clinic or hospital: • if blisters, sores in mouth, painful rash • swelling in face, hands, feet.

  29. Moderate Rashes

  30. Moderate Rashes: Management • Moderate rashes: • Usually improves with symptomatic treatment • Less frequent when begin with : • NVP 200 mg tablet once a day for 14 days • and then increase to 200 mg tablet twice a day • Treatment of moderate rash • Antihistamines • Close monitoring for developing of worsening symptoms • If no improvement after a few weeks, may need to change medication

  31. Severe and Very Severe Rash (1)

  32. Severe and Very Severe Rash (2)

  33. Symptoms that Indicate Serious Rash • Skin necrosis • Blisters or epidermal detachment • Mucous membrane erosions • Urticaria • Swelling of tongue • Confluent erythema • Facial edema or central facial involvement • Skin pain • Palpable purpura

  34. Severe and Very Severe Rash:Management • Stop the medications • May need hospitalization and intensive care • Provide nursing care as for a burn patient • Strict hand-washing & careful patient handling to prevent infection of skin • Fluid and electrolyte management, nutritional support, pain control • Daily evaluation of % of body surface area involved

  35. Liver Injury • This is a serious side effect : • Greater risk for patients with hepatitis B or C • Greater risk for women with CD4 counts over 250 • Patient education: • Important to come to clinic for regular blood tests • Report any nausea, abdominal pain, change in color of urine or stool

  36. Side Effects of Efavirenz • Common side effects: • Rash similar to nevirapine rash • Sleep disturbances • Difficulty sleeping • Vivid dreams (may be good or bad) • Serious side effects • Mental illness • Fetal abnormalities (teratrogenic)

  37. Sleep Disturbances:Symptoms • Difficulty sleeping • May have very vivid dreams – sometimes nightmares • Usually goes away in a few weeks

  38. Sleep Disturbances: Management • Patient education: • Try taking efavirenz in morning, unless it causes dizziness. • Avoid alcohol and drugs • Avoid fatty food because fat increase EFV absorption

  39. Mental Illness: Symptoms • Feelings of sadness may occur with efavirenz. • Usually goes away in a few weeks. • EFV can also cause severe mental illness, including: • Psychosis • Depression: May be mild or severe

  40. Mental Illness: Management Educate patients: • Talk to someone about how you feel • Go to the Clinic if: • Your feelings are very severe and prevent you from daily life • You are thinking of hurting yourself • You are easy to be anger or super agitated

  41. Side Effects of Second Line ARVs

  42. Side Effects of Second Line ARVs • If the first regimen doesn’t work, other combinations of medications might include some of the following: • Abacavir • Lopinavir/ritonavir • Tenofovir • DDI

  43. ABC - Hypersensitivity: Symptoms • 3-5% of patients • Fever • Malaise, Myalgias • Rash • GI symptoms • Dyspnea, pulmonary infiltrates • Usually within first 6 weeks of therapy, although late cases reported

  44. ABC - Hypersensitivity: Management • Educate patients: • Watch for: • any fever • skin rash • Fatigue • nausea, vomiting, diarrhea, abdominal pain, • or respiratory symptoms • See nurse or doctor ASAP • Discontinue drug as directed. • Restart ABC can cause cardiovascular collapse and death DO NOT RESTART EVER

  45. Side Effects ofLopinavir/r (LPV/r, Kaletra) • GI intolerance: • nausea, vomiting • diarrhea • Hyperglycemia (insulin resistance) • Fat redistribution and abnormal lipids • Occasional rash and headace

  46. Side Effects of Lopinavir/r: Management (1) If patients developsvomiting or diarrhea, educate them: • Tell your nurse or doctor • Replace fluids • Eat foods that provide nutrients and absorb liquid • Small, more frequent meals • Avoid: skins of fruits and vegetables, milk, greasy food, sweets

  47. Side Effects of Lopinavir/r: Management (2) Educate patients to go to clinic if:: • Vomiting or diarrhea occurs more than 4 times/day • There is blood in the diarrhea • There is a fever • You are thirsty but cannot eat or drink properly • You are dizzy when you stand up

  48. Side Effects of Tenofovir • Usually well tolerated • Mild side effects: nausea, vomiting, diarrhea. • Serious side effect: kidney damage • Should be used with caution in people with history of kidney problems

  49. Side Effects of ddI • Common side effects: • Peripheral neuropathy • Rash: usually mild, but severe also reported • Severe side effects: • pancreatitis • Severe hepatitis, especially if taken with d4T • Educate patients to take ddI: • 1 hour before meals or • 2 hours after meals (If not EC)

  50. Remember • Nurses should educate patients and their families: • How to recognize side effects • How to manage at home on their own • That they should not stop ARVs arbitrarily • That they should go to clinic if the side effect is severe

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