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Side Effects of Anti-retroviral Therapy

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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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

Learning Objectives

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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

Overview:Side Effects of ARVs (1)

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Patients should be carefully educated so that they can:Recognize side effects of medicationsInform health workers to have timely managementBetter adherence

Overview:Side Effects of ARVs (2)

ARV Drugs Currently Available in Vietnam

Nucleoside/Nucleotide RTI

AZT / Zidovudine

d4T / Stavudine

3TC / Lamivudine

ddI / didanosine

ABC / Abacavir

TDF / Tenofovir

Non-nucleoside RTI

NVP /Nevirapine

EFV / Efavirenz

Protease Inhibitor

Lopinavir/r (Aluvia)

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AZT + 3TC LAMZIDIVIR, Combivir

D4T + 3TC + NVP

D4T-FDC, NEVITRIO 30,

Triamune, GPOvir

AZT + 3TC + NVP AZT-FDC, LAMZITRIO

AZT + 3TC + ABC ABATRIO, Trizivir

Combination Pills Availablein Vietnam

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Side Effects of First-line ARVs

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Side Effects of d4T

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This is a common side effect of d4T Symptoms:

• Pain or tingling in hands and feet • Stocking and glove distribution• Symmetrical

Peripheral Neuropathy: Symptoms

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Nurses can:Ask patients on each visit about the symptomsEducate patients:

• Loose shoes/sandals• Light bedding• Walk a little, not a lot!• Cool water soaks• Try Ibuprofen for pain

Peripheral Neuropathy: How to Manage?

Dorsocervical enlargement (humpback)

Lipodystrophy (1)

Abdominal (visceral) adiposity

Lipodystrophy (2)

Lipodystrophy (3)

sunken cheeks prominent veins

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This is a serious side effect of d4T Symptoms:

• Abdominal pain• Nausea, and vomiting• More common among patients who use

alcohol

Pancreatitis: Symptoms

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Must STOP the medication Patients should come to clinic May need to be hospitalized

Pancreatitis: Management

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Side Effects of AZT

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Very common at start of therapy

Often improves with time:• Provide reassurance

Nausea and Vomiting: Symptoms

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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

Nausea and Vomiting: Management (1)

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Educate patients to go to the clinic or hospital if:There is blood in the vomitPain in your stomachFeverVomiting persists more than 1 dayBe thirsty, but can not eat or drink properly

Nausea and Vomiting: Management (2)

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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)

Headache (1)

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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

Headache (2)

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Bone marrow suppression: Anemia

• Severe reduction in red blood cells• Fatigue, shortness of breath

Neutropenia: • Low white blood count• Diminished ability to fight infections

Serious Side Effects (1)

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Closely monitor patients to recognize symptoms of serious side effects

May need to swap for D4T or TDF

Serious Side Effects: Management

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Side Effects of Nevirapine (NVP)

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Rash caused by NVP usually appears 2-6 first wks of treatment, but could be later

Rash: Symptoms

SymptomsMild Scattered rashes with or without itching

Moderate

• Generalized rashes with or without itching

• No systemic symptoms

Severe Generalized maculopapular rashes, allergic edema, itching, high fever

Very severe

Generalized blisters, erosion of mucus membranes, red face, conjunctivitis, high fever (39.5 - above 400C)

Mild Rash (1)

Mild Rash (2)

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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.

Mild Rash: Management

Moderate Rashes

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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

Moderate Rashes: Management

Severe and Very Severe Rash (1)

Severe and Very Severe Rash (2)

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Confluent erythema

Facial edema or central facial involvement

Skin pain Palpable purpura

Skin necrosis Blisters or

epidermal detachment

Mucous membrane erosions

Urticaria Swelling of tongue

Symptoms that Indicate Serious Rash

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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

Severe and Very Severe Rash:Management

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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

Liver Injury

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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)

Side Effects of Efavirenz

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Difficulty sleeping May have very vivid dreams – sometimes

nightmares Usually goes away in a few weeks

Sleep Disturbances: Symptoms

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Patient education: • Try taking efavirenz in morning, unless it

causes dizziness.• Avoid alcohol and drugs• Avoid fatty food because fat increase

EFV absorption

Sleep Disturbances: Management

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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

Mental Illness: Symptoms

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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

Mental Illness: Management

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Side Effects of Second Line ARVs

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If the first regimen doesn’t work, other combinations of medications might include some of the following:• Abacavir• Lopinavir/ritonavir• Tenofovir• DDI

Side Effects of Second Line ARVs

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3-5% of patients• Fever• Malaise, Myalgias• Rash• GI symptoms• Dyspnea, pulmonary infiltrates

Usually within first 6 weeks of therapy, although late cases reported

ABC - Hypersensitivity: Symptoms

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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

ABC - Hypersensitivity: Management

DO NOT RESTART EVER

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GI intolerance:• nausea, vomiting• diarrhea

Hyperglycemia (insulin resistance) Fat redistribution and abnormal lipids Occasional rash and headace

Side Effects ofLopinavir/r (LPV/r, Kaletra)

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If patients develops vomiting or diarrhea, educate them:Tell your nurse or doctorReplace fluidsEat foods that provide nutrients and absorb liquidSmall, more frequent mealsAvoid: skins of fruits and vegetables, milk, greasy food, sweets

Side Effects of Lopinavir/r: Management (1)

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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

Side Effects of Lopinavir/r: Management (2)

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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

Side Effects of Tenofovir

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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)

Side Effects of ddI

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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

Remember

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Adherence counseling for patients about side effects is really important for good adherence

To recognize side effects is the key to care and manage

Common side effects:• Peripheral neuropathy• Nausea, vomit, diarrhea• Rash…

Key Points

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Thank You!

Question?