Download Session 3 - Teaching Slides

Side Effects
of Anti-retroviral Therapy
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
1
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
2
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
3
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
4
ARV Drugs Currently Available
in Vietnam
Nucleoside/
Nucleotide RTI
Non-nucleoside
RTI
AZT / Zidovudine
NVP /Nevirapine
d4T / Stavudine
EFV / Efavirenz
3TC / Lamivudine
ddI / didanosine
ABC / Abacavir
TDF / Tenofovir
Protease Inhibitor
Lopinavir/r
(Aluvia)
Combination Pills Available
in Vietnam
AZT + 3TC
LAMZIDIVIR,
Combivir
D4T + 3TC + NVP
D4T-FDC,
NEVITRIO 30,
Triamune,
GPOvir
AZT + 3TC + NVP
AZT-FDC,
LAMZITRIO
AZT + 3TC + ABC
ABATRIO,
Trizivir
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Side Effects
of First-line ARVs
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Side Effects of d4T
8
Peripheral Neuropathy:
Symptoms


This is a common side effect of d4T
Symptoms:
• Pain or tingling in hands and feet
• Stocking and glove distribution
• Symmetrical
9
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
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Lipodystrophy (1)

Dorsocervical
enlargement
(humpback)
Lipodystrophy (2)

Abdominal
(visceral)
adiposity
Lipodystrophy (3)
sunken cheeks
prominent veins
Pancreatitis: Symptoms


This is a serious side effect of d4T
Symptoms:
• Abdominal pain
• Nausea, and vomiting
• More common among patients who use
alcohol
14
Pancreatitis: Management



Must STOP the medication
Patients should come to clinic
May need to be hospitalized
15
Side Effects of AZT
16
Nausea and Vomiting: Symptoms

Very common at start of therapy

Often improves with time:
• Provide reassurance
17
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
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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
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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)
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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
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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
22
Serious Side Effects:
Management


Closely monitor patients to recognize
symptoms of serious side effects
May need to swap for D4T or TDF
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Side Effects of
Nevirapine (NVP)
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Rash: Symptoms

Rash caused by NVP usually appears 2-6 first
wks of treatment, but could be later
Symptoms
Mild
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
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fever (39.5 - above 400C)
Mild Rash (1)
Mild Rash (2)
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.
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Moderate Rashes
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
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Severe and Very Severe Rash (1)
Severe and Very Severe Rash (2)
Symptoms that
Indicate Serious Rash




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
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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
34
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
35
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)
36
Sleep Disturbances:
Symptoms



Difficulty sleeping
May have very vivid dreams – sometimes
nightmares
Usually goes away in a few weeks
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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
38
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
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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
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Side Effects
of Second Line ARVs
41
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
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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
43
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
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Side Effects of
Lopinavir/r (LPV/r, Kaletra)

GI intolerance:
• nausea, vomiting
• diarrhea



Hyperglycemia (insulin resistance)
Fat redistribution and abnormal lipids
Occasional rash and headace
45
Side Effects of Lopinavir/r:
Management (1)
If patients develops vomiting 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
46
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
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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
48
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)
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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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Key Points



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…
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Thank You!
Question?
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