Download Prioritized Problem Lists - PACT Clinic

Prioritized Problem Lists
TT – 51yo female – TT abruptly stopped taking all of her antiretroviral therapy
approximately 1 month ago and came into the clinic to get counseled on her new
regimen. She developed mutations due to the discontinuation of her medications which
the PACT clinic had to take into account when prescribing her new therapy.
Problem List:
1. Human Immunodeficiency Virus with mutations at K103N primarily as well as
333 and 101
 Patient reported to the PACT clinic for a change in antiretroviral therapy
requiring patient counseling.
 New antiretroviral regimen:
o Darunavir 800mg PO daily
o Ritonavir 100mg PO daily
o emtricitabine/tenofovir 1 tablet PO daily.
o Patient will begin this regimen as soon as the medications
are available from her pharmacy.
 CD4 count: 34 (2/15/12) and Viral Load: 271,880 (10/24/2011)
 Monitoring:
o CD4 count baseline and every 3 months, extended to every
6 months when stable for 2-3 years.
Goal: increase of 50-150 cells/mm per year
o Viral Load: baseline and 2-8 weeks after
initiation/modification of therapy, and every 6 weeks until
levels fall below <50 copies/mL. Once stable, measure
viral load every 3 months.
Goal: complete viral suppression in 12-24 weeks (<50
copies/mL)
o LFTs and lipid panel at baseline and every 3-6 months
throughout therapy
2. Two Previous Pulmonary Embolisms requiring lifelong anticoagulation therapy
 Current warfarin dosing: 20mg daily on Monday, Wednesday, and Friday.
15mg PO daily on Tuesday, Thursday, Saturday, and Sunday.
 Due to new antiretroviral therapy, warfarin dosing may have to be
increased by 10-20% in order to maintain an appropriate INR. If a dose
increase is needed, consider switching to 20mg on Tuesday, Thursday,
Saturday, and Sunday and 15mg on Monday, Wednesday, and Friday.
 INR: 3.6 (2/1/12)
 Monitoring:
o INR at baseline, and 1 week following HIV regimen
adjustment. Once stable, INR assessment every 4 weeks.
Signs of abnormal bleeding, unusual bruising
o Goal: INR: 2-3
3. PCP Prophylaxis
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Continue atovaquone 1500mg QD
Discontinue therapy when CD4 >200 for 3 consecutive months
Monitoring:
o CD4 baseline and every 3 months. Before discontinuation,
CD4 count every month for at least 3 months. Rash,
abdominal pain, arterial blood gases every 3 months
Goal: avoid life threatening opportunistic infection
4. MAC Prophylaxis
 Initiate Azithromycin 1200mg PO once weekly
 May discontinue when CD4 >100 for at least 3 consecutive months
 Monitoring: fever, CBC with diff every 3 months, diarrhea, vomiting
 Goal: Prevent life threatening opportunistic infections
5. Hypertension uncontrolled due to poor adherence
 Continue lisinopril 5mg and HCTZ 25mg daily.
 Medication compliance needs to be stressed to patient.
 Monitoring:
o Instruct patient to check BP daily at Walgreens. Call PACT
clinic if BP >140/95 on 2 separate occasions.
o If blood pressure remains uncontrolled, may consider
increasing lisinopril to 10 mg, or adding amlodipine 5mg
daily.
 Goal: BP: <140/90 mmHg
6. Smoking Cessation Therapy Needed
 Patient reports smoking 3 cigarettes daily
 Initiate 2mg Nicotine gum. 1 piece every 2 hours and as needed for 6
weeks to control cravings. Maximum dose = 24 pieces/daily.
 Recommended smoking cessation counseling sessions as needed
throughout therapy to stress importance of smoking cessation and
medication adherence.
 Monitoring:
o Monitor # of cigarettes being smoked daily/cravings to
smoke
o Goal: complete cessation of smoking
WB – 56yo male – WB has stopped taking all of his medications and is recently being
restarted on a new HAART regimen. He has begun having problems with PML, but has
recently seen a slight improvement with his new HAART regimen.
Problem List:
1. Acquired Immune-Deficiency Syndrome
 Continue current HAART regimen:
o Tenofovir-emtricitabine: 1 tablet PO daily
o Raltegravir: 400mg PO twice daily
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o Darunavir: 600mg PO twice daily
o Ritonavir: 100mg PO twice daily
CD4 Count: 15 (3/8/2012) Viral Load: 5,135 copies/mL (3/12/2012)
Monitoring:
o CD4 count baseline and every 3 months, extended to every 6
months when stable for 2-3 years.
Goal: increase of 50-150 cells/mm per year
o Viral Load: baseline and 2-8 weeks after initiation/modification of
therapy, and every 6 weeks until levels fall below <50 copies/mL.
Once stable, measure viral load every 3 months.
Goal: complete viral suppression in 12-24 weeks (<50 copies/mL)
o LFTs and lipid panel at baseline and every 3-6 months throughout
therapy
2. Progressive Multifocal Leukoencephalopathy (PML)
 Currently, there is no effective cure for PML. The disease shows
improvement when the patient rebuilds the immune system, so by the
patient being compliant on the HAART regimen, the PML should resolve.
 Monitoring:
o CD4 count and viral load every 4 weeks, ophthalmic exam every 3
months (call clinic immediately if any changes in vision)
o Vision changes, difficulty reading/writing, ophthalmic examination
monthly until PML resolved
 Goal: Return to baseline vision in terms of color/reading.
3. Chronic Right Eye CMV Retinitis
 Continue current regimen:
o Valganciclovir: 900mg PO daily
o Dexamethasone/Neomycin/Polymyxin B Ophthalmic Ointment:
0.5 cm in the right eye at bedtime as needed
o Dorzolamide-timolol ophthalmic solution: 1 drop into right eye
twice daily
 Monitoring: ophthalmic exams every 6 months, CBC with differential
every 3 months, episodes of diarrhea, nausea/vomiting, fever
 Goal: Avoid removal of the right eye.
4. PCP/Toxoplasmosis Prophylaxis
 Continue current regimen:
o Sulfamethoxazole/Trimethoprim 800mg-160mg PO daily
o May discontinue when CD4 >200 for at least 3 consecutive months
 Monitoring: rash, fever, CBC with diff every 3 months, serum potassium
every 3 months
 Goal: Prevent life threatening opportunistic infections
5. MAC Prophylaxis
 Continue current regimen:
o Azithromycin 1200mg PO once weekly
o May discontinue when CD4 >100 for at least 3 consecutive months
 Monitoring: fever, CBC with diff every 3 months, diarrhea, vomiting
 Goal: Prevent life threatening opportunistic infections
6. Unconrolled Hypertension due to poor medication adherence
 BP: 133/100 mmHg (3/13/12)
 Continue lisinopril 10mg PO daily. Patient was instructed to check and
record BP daily at home with automatic blood pressure monitor
o Increase to lisinopril 20mg PO daily if blood pressure still
uncontrolled at f/u visit despite good adherence
 Monitoring: dry cough, headaches, serum potassium every 3 months,
 Goal: BP < 140/90 mmHg