Download Managing toxicity, side effects and adherence.

Managing toxicity, side effects
and adherence.
Maren Koros
CHIVA 2015
Definitions
• What are side effects?
• Side effects
Side effects are unwanted symptoms caused by
medical treatment.
• Can a side effect be therapeutic?
Yes
It’s an effect, whether therapeutic or adverse,
that is secondary to the one intended.
Adverse drug reaction.
An injury caused by taking medication.
Classification based upon dose dependence and predictability
– Type A and Type B
• Type A - augmentation of the active pharmacologic properties of the
drug. Generally less severe and more frequent than Type B reactions.
• Type B- the are often unexpected, these can range in severity from
nuisance to life threatening. They are usually idiosyncratic.
– make many patients unwilling to take drugs on a regular basis,
and this lack of compliance represents a major practical
limitation of pharmacotherapy.
• Adverse drug reactions may be more likely in patients with
pre-existing conditions, such as liver or kidney dysfunction,
depressed immune function, or pregnancy
Minimising Harm
• Drug chosen to treat a particular condition
should minimise the patient’s susceptibility to
adverse effects and where co-morbidities exist
have minimal detrimental effects in the
patient’s other diseases and treatment. To
achieve this, contra-indications, cautions and
side-effects, interactions of the drugs should
be reviewed regularly.
Drug toxicity
• Degree to which a drug can cause harm to an
individual. These can occur at many different
time scales.
• Acute toxicity – can occur as a result of a
single exposure and within minutes to hours
of the exposure
• Chronic toxicity – occurs over a prolonged
period of time.
Case Presentation
• 16 year old young man has been on Truvada
efavirenz for 7 years.
• Weight 70 kgs
• Very Compliant,
• VL- BDL
• FBCs and U&Es unremarkable.
• Complaining of sleep disturbances, He is
wondering if she can change medication…..
What would you do
• A. Nothing
• B. Encourage him to consider sleep
medication
• C. Take time to consider medication.
• D. Change medication.
What would you change to and why
• Decision is made to change to Raletegravir
400mg BD.
• Review within 8 weeks.
• Week 6 – patient develops ear infection sees
GP – prescribed Flumetasone/Clioquinol Ear
Drops solution bd for 7 days
• On day 5 patient develops rash on ear and
side of face so stops using ear drops.
Cont’d
• 2 weeks later the rash is generally widespread,
(8 week appt). What do you do?
• All treatment withheld.
• In the evening, patient attends ED – Temperature,
rigors, widespread rash, red angry, some skin peeling –
admitted to general ward. Diagnosis cellulitis
- Gen med ward for 5 days treated with I.V. flucloxacillin.
- Then discharged.
• All parameters return to baseline.
• What ARVs would you restart?
Cont
• Truvada + Raltegravir restarted.
• 1 week post re-challenge – patient is admitted via
ED, - rash skin, peeling, pyrexia.
• 24 hrs later blistering occurs in the mouth and
lips and skin condition worsens.
• Diagnosis SJS/TENS
• Patient is admitted to ITU –turbulent recovery
requiring skin grafting.
• What would you have done different.
Microsoft Word
Document
Causes of drug toxicities
• Drug-disease interactions
Additive effects of concurrent therapies
Reduced renal excretion of a drug may produce
toxicity
Sensitivity to some drugs is increased even if
elimination is not impaired
• Drug-food interactions
• Herbal remedies
• OTC medication
Management and prevention
•
In children who have severe or life-threatening toxicity, all antiretroviral drugs
should be stopped immediately. Once symptoms of toxicity have resolved,
antiretroviral therapy should be resumed with substitution of a different
antiretroviral drug or drugs for the offending agent(s)
•
When modifying therapy because of toxicity or intolerance to a specific drug in
children with virologic suppression, changing one drug in a multidrug regimen is
permissible; if possible, an agent with a different toxicity and side-effect profile
should be chosen .
•
The toxicity and the medication presumed responsible should be documented in
the medical record and the caregiver and patient advised of the drug-related
toxicity.
•
Dose reduction is not a recommended option for management of ARV toxicity,
except for those few antiretroviral drugs for which a therapeutic range of plasma
concentrations detected by therapeutic drug monitoring correlates with toxicity .
Manamement
• Identification and management of Side
effects/ Toxicity can be complex and usually
requires a multi disciplinary approach.
• More importantly requires patient education
to alert them SE which are serious and what
to do about these reactions.
• Traffic light system (or an app) can be used to
create a selection of SE and whom to report to
and discuss when these occur.
Reporting
• The MHRA recommends that all ADRs that are
serious, medically significant, or results in
harm should be reported.
• https://yellowcard.mhra.gov.uk/
• Patients and healthcare workers can report
• Associated with newer drugs and vaccines
( black triangle) should be reported.
References
• http://www.nhs.uk/chq/pages/997.aspx?cate
goryid=73&subcategoryid=108
• (https://www.blackwellpublishing.com/content/BPL_Images/
Content_store/Sample_chapter/0632045868/cobertsample.p
dfunpredictable or idiosyncratic.)
• http://downloads.lww.com/wolterskluwer_vit
alstream_com/samplecontent/9780781783552_Golan/samples/929
00_CH5.pdf
• Fauci, Anthony S., et al. Harrison's Principles of
Internal Medicine. 17th ed. United States:
McGraw-Hill Professional, 2008
• BNF C
• BNF
• https://aidsinfo.nih.gov/guidelines/html/2/pe
diatric-arv-guidelines/368/overview