Aids[1]

AIDS: Definition: Defect in t-cell mediated immunity that allows the development of fatal opportunistic infections. An illness characterized by laboratory evidence of HIV infection coexisting with one or more indicator diseases such as herpes simplex virus, cytomegalovirus, myobacteria, candidal infection, Pneumocystis carinii, Kaposi’s sarcoma, wasting syndrome, or dementia CAUSES: Exposure to blood containing HIV, transfusions, contaminated needles, handling of blood, or in utero. Exposure to semen and vaginal secretions containing HIV: unprotected sexual intercourse or handling of semen and vaginal secretions. PATHO: HIV is transmitted by contact with infected blood or body fluids - HIV infected lymphocytes are carried in semen, vaginal secretions, and blood. - - infected lymphocytes in semen and vaginal secretions are transferred through minute breaks in the skin and mucosa - Infected lymphocytes in blood are transferred via transfusion, fetal circulation, and minute breaks in the skin and mucosa. ASSESSMENT FINDINGS: Fatigue Weakness Anorexia Weight loss Recurrent diarrhea Fever Lymphadenopathy Pallor Night sweats Malnutrition Disorientation, confusion, dementia Opportunistic infections DIAGNOSTICS: Enzyme linked immunosorbent assay (ELISA): Positive HIV antibody titer Western Blot: Positive CD4+ levels: less than 200 cells/mm MEDICAL MANAGEMENT IV therapy: hydration, electrolyte replacement, and saline lock O2 therapy Activity as tolerated, active and passive ROM exercises Montior VS, I&O Pulse oximetry, daily weights, and laboratory studies

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Nutritional support: TPN if the pt. can’t take food by mouth Treatments: chest physiotherapy, postural drainage, and incentive spirometry Transfusion therapy: fres frozen plasma, platelets and packed RBC’s Antiobiotics: Pentamidine (Pentam) Classifications -------------------------------------------------------------------------------Therapeutic Classification: antiprotozoals Indications -------------------------------------------------------------------------------• IV: Treatment of Pneumocystis carinii pneumonia (PCP). • Inhaln: Prevention of PCP in AIDS or HIV-positive patients who have had PCP or who have a peripheral CD4 lymphocyte count of 200/mm³. Unlabeled Uses: • Inhaln: Treatment of PCP. Action -------------------------------------------------------------------------------• Appears to disrupt DNA or RNA synthesis in protozoa. • Also has a direct toxic effect on pancreatic islet cells. Therapeutic Effects: • Death of susceptible protozoa. Pharmacokinetics -------------------------------------------------------------------------------Absorption: Minimal systemic absorption occurs following inhalation. Distribution: Widely and extensively distributed but does not cross the blood-brain barrier. Concentrates in liver, kidneys, lungs, and spleen, with prolonged storage in some tissues. Metabolism/Excretion: 1–30% excreted unchanged by the kidneys. Remainder of metabolic fate unknown. Half-life: 6.4–9.4 hr (increased in renal impairment). Contraind./Precautions --------------------------------------------------------------------------------

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Contraindicated in: • History of previous anaphylactic reaction to pentamidine. Use Cautiously in: • Hypotension. • Hypertension. • Hypoglycemia. • Hyperglycemia. • Hypocalcemia. • Leukopenia. • Thrombocytopenia. • Anemia. • Renal impairment (dose reduction required). • Diabetes mellitus. • Liver impairment. • Cardiovascular disease. • Bone marrow depression, previous antineoplastic therapy, or radiation therapy. • OB: Pregnancy or lactation (safety not established during pregnancy; breastfeeding not recommended). Adv. Reactions/Side Effects --------------------------------------------------------------------------------

For parenteral form, unless otherwise indicated CNS: anxiety, headache, confusion, dizziness , hallucinations. EENT: inhalation: burning in throat. Resp: inhalation: bronchospasm, cough. CV: arrhythmias, hypotension. GI: pancreatitis, abdominal pain, anorexia, drug-induced hepatitis , nausea, unpleasant metallic taste, vomiting. GU: nephrotoxicity . Derm: pallor, rash . Endo: hypoglycemia , hyperglycemia.

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F and E: hyperkalemia , hypocalcemia. Hemat: anemia, leukopenia , thrombocytopenia. Local: • IV — phlebitis, pruritus, urticaria at IV site, IM, — sterile abscesses at IM sites . Misc: allergic reactions including anaphylaxis, Stevens-Johnson syndrome, chills , fever. Interactions -------------------------------------------------------------------------------Interactions listed for parenteral administration Drug-Drug: • : Concurrent use with erythromycin IV may risk of potentially fatal arrhythmias. • Additive nephrotoxicity with other nephrotoxic agents, including aminoglycosides, amphotericin B, and vancomycin. • Additive bone marrow depression with antineoplastics or previous radiation therapy. • risk of pancreatitis with didanosine. • risk of nephrotoxicity, hypocalcemia, and hypomagnesemia with foscarnet. Route/Dosage -------------------------------------------------------------------------------• IV (Adults and Children ): 4 mg/kg once daily for 14–21 days (longer treatment may be required in AIDS patients; some patients may respond to 3 mg/kg/day). • Inhaln (Adults): NebuPent, Pentacarinat — 300 mg q 4 wk, using a Respirgard II jet nebulizer (150 mg q 2 wk has also been used). Pneumopent — 60 mg q 24–72 hr for 5 doses over a 2-wk period, then q 2 wk using a Fisoneb ultrasonic nebulizer . • Inhaln (Children >5 yr): NebuPent, Pentacarinat — 300 mg q 4 wk, using a Respirgard II jet nebulizer (for patients who cannot tolerate trimethoprim/sulfamethoxazole; unlabeled). Implementation -------------------------------------------------------------------------------• Pentamidine must be given on a regular schedule for the full course of therapy. Administer missed doses as soon as remembered. If almost time for the next dose, skip the missed dose and return to the regular schedule. Do not double doses. • IM: Dilute 300 mg of pentamidine with 3 ml of sterile water for injection for a concentration of 100 mg/ml. IM administration should be used only for patients with adequate muscle mass and given deep IM via Z-track technique. May cause sterile abscesses.

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• Intermittent Infusion: To reconstitute, add 3–5 ml of sterile water for injection or D5W to each 300-mg vial for a concentration of 100, 75, or 60 mg/ml, respectively. Withdraw dose and dilute further in 50–250 ml of D5W. Solution is stable for 48 hr at room temperature. Discard unused portions. • Not to exceed 6 mg/ml for administration. • Rate: Administer slowly over 1–2 hr. • Y-Site Compatibility: › diltiazem. › zidovudine. • › › › › › › › › ›

Y-Site Incompatibility: › aldesleukin. cefazolin. cefotaxime. cefoxitin. ceftazidime. ceftriaxone. fluconazole. foscarnet. lansoprazole. linezolid.

• Inhaln: If using inhalation bronchodilator, administer bronchodilator 5–10 min prior to pentamidine administration. › Administer in a well-ventilated area. › Administration with patient in supine or recumbent position appears to provide a more uniform distribution of pentamidine. › NebuPent or Pentacarinat: Dilute 300 or 600 mg (for prophylaxis or treatment, respectively) in 6 ml of sterile water for injection. Place reconstituted solution into Respirgard II nebulizer. Do not dilute with 0.9% NaCl or admix with other medications, as solution will form a precipitate. Do not use Respirgard II nebulizer for other medications. › Administer inhalation dose through nebulizer until chamber is empty, approximately 30–45 min. › Pneumopent: Remove rubber stopper and set upside down on a clean surface for use later. Add 3–5 ml of sterile water for inhalation or preservative-free water for injection to vial and replace rubber stopper. Do not use tap water or 0.9% NaCl. Powder should dissolve immediately; if not, shake gently to mix. Solution should be clear and colorless; do not use if cloudy. Solution is stable for 24 hr at room temperature or 48 hr if refrigerated. Place entire reconstituted contents into Fisoneb ultrasonic nebulizer . › Administer with the flow rate of the nebulizer at the midflow mark over approximately 15 min until the chamber is empty. Assessment --------------------------------------------------------------------------------

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• Assess patient for infection (vital signs, sputum, WBC) and monitor respiratory status (rate, character, lung sounds, dyspnea, sputum) at beginning of and throughout therapy. • Obtain specimens for culture and sensitivity prior to initiating therapy. First dose may be given before receiving results. • IV, IM: Monitor blood pressure frequently during and following IM or IV administration of pentamidine. Patient should be lying down during administration. Sudden, severe hypotension may occur following a single dose. Resuscitation equipment should be immediately available. • Assess patient for signs of hypoglycemia (anxiety; chills; diaphoresis; cold, pale skin; headache; increased hunger; nausea; nervousness; shakiness) and hyperglycemia (drowsiness; flushed, dry skin; fruit-like breath odor; increased thirst; increased urination; loss of appetite), which may occur up to several months after therapy is discontinued. • Pulse and ECG should be monitored prior to and periodically during course of therapy. Fatalities due to cardiac arrhythmias, tachycardia, and cardiotoxicity have been reported. • Inhaln: A tuberculin skin test, chest x-ray, and sputum culture should be performed prior to administration to rule out tuberculosis. Lab Test Considerations: • IM, IV — Monitor blood glucose concentrations prior to, daily during, and for several months following therapy. Severe hypoglycemia and permanent diabetes mellitus have occurred. › Monitor BUN and serum creatinine prior to and daily during therapy to monitor for nephrotoxicity. Concentrations may be . › Monitor CBC and platelet count prior to and every 3 days during therapy. Pentamidine may cause leukopenia, anemia, and thrombocytopenia. › May cause serum bilirubin, alkaline phosphatase, AST, and ALT concentrations. Monitor liver function tests prior to and every 3 days during therapy. › Monitor serum calcium and magnesium concentrations prior to and every 3 days during therapy;may cause hypocalcemia and hypomagnesemia. › May cause serum potassium concentrations.

Patient/Family Teaching --------------------------------------------------------------------------------

• Inform patient of the importance of completing the full course of pentamidine therapy, even if feeling better. • IV: Instruct patient to notify health care professional promptly if fever; sore throat; signs of infection; bleeding of gums; unusual bruising; petechiae; or blood in stool, urine, or emesis occurs. Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush and electric razor and to avoid falls. Patient should not be given IM injections or rectal thermometers. Patient should be cautioned not to drink alcoholic beverages or take medication containing aspirin or NSAIDs, as these may

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precipitate gastric bleeding. › Caution patient to make position changes slowly to minimize orthostatic hypotension. • Inhaln: Advise patient that an unpleasant metallic taste may occur with pentamidine administration but is not significant. › Inform patients who continue to smoke that bronchospasm and coughing during therapy are more likely. Trimethoprim/sulfamethoxazole (Bactrim) Indications -------------------------------------------------------------------------------• Treatment of. › Bronchitis. › Shigella enteritis. › Otitis media. › Pneumocystis carinii pneumonia (PCP). › Urinary tract infections. › Traveler’s diarrhea. • Prevention of PCP in HIV-positive patients. Unlabeled Uses: • Biliary tract infections, osteomyelitis, burn and wound infections, chlamydial infections, endocarditis, gonorrhea, intra-abdominal infections, nocardiosis, rheumatic fever prophylaxis, sinusitis, eradication of meningococcal carriers, prophylaxis of urinary tract infections, and an alternative agent in the treatment of chancroid. • Prevention of bacterial infections in immunosuppressed patients. Action -------------------------------------------------------------------------------• Combination inhibits the metabolism of folic acid in bacteria at two different points. Therapeutic Effects: • Bactericidal action against susceptible bacteria.

Spectrum: • Active against many strains of gram-positive aerobic pathogens including. › Streptococcus pneumoniae. › Staphylococcus aureus. › Group A beta-hemolytic streptococci.

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› Nocardia. › Enterococcus. • › › › › › ›

Has activity against many aerobic gram-negative pathogens, such as. › Acinetobacter. Enterobacter. Klebsiella pneumoniae. Escherichia coli. Proteus mirabilis. Shigella. Haemophilus influenzae, including ampicillin-resistant strains.

• P. carinii (a protozoa). • Not active against Pseudomonas aeruginosa. Pharmacokinetics -------------------------------------------------------------------------------Absorption: Well absorbed from the GI tract. Distribution: Widely distributed. Crosses the blood-brain barrier and placenta and enters breast milk. Metabolism/Excretion: Some metabolism by the liver (20%); remainder excreted unchanged by the kidneys. Half-life: Trimethoprim — 6–11 hr; sulfamethoxazole — 9–12 hr, both prolonged in renal failure. Contraind./Precautions -------------------------------------------------------------------------------Contraindicated in: • • • •

Hypersensitivity to sulfonamides or trimethoprim. Megaloblastic anemia secondary to folate deficiency. Severe renal impairment. Pregnancy, lactation, or children <2 mo (can cause kernicterus in neonates).

Use Cautiously in: • Impaired hepatic or renal function (dosage reduction required if CCr <30 ml/min). • HIV-positive patients (increased incidence of adverse reactions).

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Assessment -------------------------------------------------------------------------------• Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy. • Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results. • Inspect IV site frequently. Phlebitis is common. • Assess patient for allergy to sulfonamides. • Monitor intake and output ratios. Fluid intake should be sufficient to maintain a urine output of at least 1200–1500 ml daily to prevent crystalluria and stone formation. Lab Test Considerations: • Monitor CBC and urinalysis periodically during therapy. › May produce serum bilirubin, creatinine, and alkaline phosphatase. Patient/Family Teaching --------------------------------------------------------------------------------

• Instruct patient to take medication around the clock and to finish drug completely as directed, even if feeling well. Take missed doses as soon as remembered unless almost time for next dose. Advise patient that sharing of this medication may be dangerous. • Instruct patient to notify health care professional if fever and diarrhea develop, especially if diarrhea contains blood, mucus, or pus. Advise patient not to treat diarrhea without consulting health care professional. • Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions. • Advise patient to notify health care professional if skin rash, sore throat, fever, mouth sores, or unusual bleeding or bruising occurs. • Instruct patient to notify health care professional if symptoms do not improve within a few days. • Emphasize importance of regular follow-up exams to monitor blood counts in patients on prolonged therapy. • Home Care Issues: Instruct family or caregiver on dilution, rate, and administration of drug and proper care of IV equipment.

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Highly active antiretroviral therapy (HAART) Nucleoside reverse transcriptase inhibitors: Zidovudine (Retrovir): Indications -------------------------------------------------------------------------------• HIV infection (with other antiretrovirals). • Reduction of maternal/fetal transmission of HIV. Action -------------------------------------------------------------------------------• Following intracellular conversion to its active form, inhibits viral RNA synthesis by inhibiting the enzyme DNA polymerase (reverse transcriptase). • Prevents viral replication. Therapeutic Effects: • Virustatic action against selected retroviruses. • Slowed progression and decreased sequelae of HIV infection. • Decreased viral load and improved CD4 cell counts. • Decreased transmission of HIV to infants born to HIV-infected mothers. Pharmacokinetics -------------------------------------------------------------------------------Absorption: Well absorbed following oral administration. Distribution: Widely distributed; enters the CNS. Crosses the placenta. Metabolism/Excretion: Mostly (75%) metabolized by the liver; 15–20% excreted unchanged by the kidneys. Half-life: 1 hr. Contraind./Precautions --------------------------------------------------------------------------------

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Contraindicated in: • Hypersensitivity. • Lactation. Use Cautiously in: • Decreased bone marrow reserve (dosage reduction required for anemia or granulocytopenia). • Severe hepatic or renal disease (dose modification may be required). Adv. Reactions/Side Effects --------------------------------------------------------------------------------

CNS: seizures, headache, weakness , anxiety, confusion, decreased mental acuity, dizziness, insomnia , mental depression, restlessness, syncope. GI: abdominal pain, diarrhea, nausea, anorexia, drug-induced hepatitis, dyspepsia, oral mucosa pigmentation , vomiting. Derm: nail pigmentation . Endo: gynecomastia. Hemat: anemia, granulocytopenia , pure red-cell aplasia, thrombocytosis . MS: back pain, myopathy . Neuro: tremor. Interactions -------------------------------------------------------------------------------Drug-Drug: • bone marrow depression with other agents having bone marrow–depressing properties, antineoplastics,radiation therapy, or ganciclovir. • neurotoxicity may occur with acyclovir. • Toxicity may be by concurrent administration of probenecid or fluconazole. • Zidovudine levels are by clarithromycin. Assessment --------------------------------------------------------------------------------

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• Assess patient for change in severity of symptoms of HIV and for symptoms of opportunistic infections during therapy. Lab Test Considerations: • Monitor viral load and CD4 counts prior to and periodically during therapy. › Monitor CBC every 2 wk during the first 8 wk of therapy in patients with advanced HIV disease, and decrease to every 4 wk after the first 2 mo if zidovudine is well tolerated or monthly during the first 3 mo and every 3 mo thereafter unless indicated in patients who are asymptomatic or have early symptoms. Commonly causes granulocytopenia and anemia. Anemia may occur 2–4 wk after initiation of therapy. Anemia may respond to epoetin administration (see epoetin monograph). Granulocytopenia usually occurs after 6–8 wk of therapy. Consider dose reduction, discontinuation of therapy, or blood transfusions if hemoglobin is <7.5 g/dl or reduction of >25% from baseline and/or granulocyte count is <750/mm³ or reduction of >50% from baseline. Treatment with sargramostim may be necessary (see sargramostim monograph). Therapy may be gradually resumed when bone marrow recovery is evident. Patient/Family Teaching -------------------------------------------------------------------------------• Instruct patient to take zidovudine as directed, around the clock, even if sleep is interrupted. Emphasize the importance of compliance with therapy, not taking more than prescribed amount, and not discontinuing without consulting health care professional. Take missed doses as soon as remembered unless almost time for next dose; do not double doses. Inform patient that long-term effects of zidovudine are unknown at this time. • Instruct patient that zidovudine should not be shared with others. • Zidovudine may cause dizziness or fainting. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. • Inform patient that zidovudine does not cure HIV and does not reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom during sexual contact and avoid sharing needles or donating blood to prevent spreading the AIDS virus to others. • Instruct patient to notify health care professional promptly if fever, sore throat, or signs of infection occur. Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush, to use caution when using toothpicks or dental floss, and to have dental work done prior to therapy or deferred until blood counts return to normal. Patient should also notify health care professional if shortness of breath, muscle aches, symptoms of hepatitis or pancreatitis, or other unexpected reactions occur. • Advise patient to avoid taking any RX or OTC medications or herbal products without consulting health care professional. • Emphasize the importance of regular follow-up exams and blood counts to determine progress and monitor for side effects.

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AZT Indications -------------------------------------------------------------------------------• HIV infection (with other antiretrovirals). • Reduction of maternal/fetal transmission of HIV. Action -------------------------------------------------------------------------------• Following intracellular conversion to its active form, inhibits viral RNA synthesis by inhibiting the enzyme DNA polymerase (reverse transcriptase). • Prevents viral replication. Therapeutic Effects: • Virustatic action against selected retroviruses. • Slowed progression and decreased sequelae of HIV infection. • Decreased viral load and improved CD4 cell counts. • Decreased transmission of HIV to infants born to HIV-infected mothers. Pharmacokinetics -------------------------------------------------------------------------------Absorption: Well absorbed following oral administration. Distribution: Widely distributed; enters the CNS. Crosses the placenta. Metabolism/Excretion: Mostly (75%) metabolized by the liver; 15–20% excreted unchanged by the kidneys. Half-life: 1 hr. Contraind./Precautions -------------------------------------------------------------------------------Contraindicated in: • Hypersensitivity. • Lactation. Use Cautiously in: • Decreased bone marrow reserve (dosage reduction required for anemia or granulocytopenia). • Severe hepatic or renal disease (dose modification may be required).

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Adv. Reactions/Side Effects --------------------------------------------------------------------------------

CNS: seizures, headache, weakness , anxiety, confusion, decreased mental acuity, dizziness, insomnia , mental depression, restlessness, syncope. GI: abdominal pain, diarrhea, nausea, anorexia, drug-induced hepatitis, dyspepsia, oral mucosa pigmentation , vomiting. Derm: nail pigmentation . Endo: gynecomastia. Hemat: anemia, granulocytopenia , pure red-cell aplasia, thrombocytosis . MS: back pain, myopathy . Neuro: tremor. Interactions -------------------------------------------------------------------------------Drug-Drug: • bone marrow depression with other agents having bone marrow–depressing properties, antineoplastics,radiation therapy, or ganciclovir. • neurotoxicity may occur with acyclovir. • Toxicity may be by concurrent administration of probenecid or fluconazole. • Zidovudine levels are by clarithromycin. Assessment -------------------------------------------------------------------------------• Assess patient for change in severity of symptoms of HIV and for symptoms of opportunistic infections during therapy. Lab Test Considerations: • Monitor viral load and CD4 counts prior to and periodically during therapy. › Monitor CBC every 2 wk during the first 8 wk of therapy in patients with advanced HIV disease, and decrease to every 4 wk after the first 2 mo if zidovudine is well tolerated or monthly during the first 3 mo and every 3 mo thereafter unless indicated in patients who are asymptomatic or have early symptoms. Commonly causes granulocytopenia and anemia. Anemia may occur 2–4 wk after initiation of therapy. Anemia may respond to epoetin administration (see epoetin monograph). Granulocytopenia usually occurs after 6–8 wk of therapy. Consider dose reduction, discontinuation of therapy, or blood transfusions if hemoglobin is <7.5 g/dl or reduction

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of >25% from baseline and/or granulocyte count is <750/mm³ or reduction of >50% from baseline. Treatment with sargramostim may be necessary (see sargramostim monograph). Therapy may be gradually resumed when bone marrow recovery is evident. Patient/Family Teaching --------------------------------------------------------------------------------

• Instruct patient to take zidovudine as directed, around the clock, even if sleep is interrupted. Emphasize the importance of compliance with therapy, not taking more than prescribed amount, and not discontinuing without consulting health care professional. Take missed doses as soon as remembered unless almost time for next dose; do not double doses. Inform patient that long-term effects of zidovudine are unknown at this time. • Instruct patient that zidovudine should not be shared with others. • Zidovudine may cause dizziness or fainting. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. • Inform patient that zidovudine does not cure HIV and does not reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom during sexual contact and avoid sharing needles or donating blood to prevent spreading the AIDS virus to others. • Instruct patient to notify health care professional promptly if fever, sore throat, or signs of infection occur. Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush, to use caution when using toothpicks or dental floss, and to have dental work done prior to therapy or deferred until blood counts return to normal. Patient should also notify health care professional if shortness of breath, muscle aches, symptoms of hepatitis or pancreatitis, or other unexpected reactions occur. • Advise patient to avoid taking any RX or OTC medications or herbal products without consulting health care professional. • Emphasize the importance of regular follow-up exams and blood counts to determine progress and monitor for side effects.

Zalcitabine: Indications --------------------------------------------------------------------------------

• Management of HIV infection in combination with other antiretrovirals. Action -------------------------------------------------------------------------------• Following intracellular conversion to its active form, inhibits viral DNA synthesis and subsequent viral replication.

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Therapeutic Effects: • Slowed progression and decreased sequelae of HIV infection. • Decreased viral load and increased CD4 cell count. Pharmacokinetics -------------------------------------------------------------------------------Absorption: Well absorbed following oral administration (80%). Distribution: Distributes into intracellular fluid. Crosses the blood-brain barrier. Remainder of distribution not known. Metabolism/Excretion: 70% excreted by the kidneys. Half-life: 2 hr. Contraind./Precautions -------------------------------------------------------------------------------Contraindicated in: • Hypersensitivity. Use Cautiously in: • Patients with renal impairment (dosage modification recommended if CCr is <40 ml/min). • Patients with any signs of peripheral neuropathy (zalcitabine should be briefly discontinued and restarted at 50% of the previous dose if improvement occurs). • Dosage modification may be required for other concurrent toxicities including hematologic toxicity and toxicity from other therapies. • Pre-existing liver disease, including hepatitis B or history of alcohol abuse (increased risk of drug-induced liver function abnormalities). • History of pancreatitis or hypertriglyceridemia. • History of cardiomyopathy or CHF. • Safe use in pregnancy, lactation, or children has not been established. Adv. Reactions/Side Effects --------------------------------------------------------------------------------

CNS: confusion, dizziness , fatigue, headache, impaired concentration. EENT: pharyngitis.

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CV: cardiomyopathy, CHF, chest pain . GI: pancreatitis/hepatomegaly/steatosis , oral ulcers, abdominal pain, anorexia, diarrhea , dysphagia, esophageal ulcerations increased liver enzymes, nausea, vomiting . Derm: dermatitis, pruritus , rash. F and E: lactic acidosis. Hemat: leukopenia, neutropenia . MS: arthralgia, myalgia . Neuro: peripheral neuropathy . Misc: hypersensitivity reactions , weight loss. Interactions -------------------------------------------------------------------------------Drug-Drug: • Risk of neuropathy is increased by concurrent use of other drugs causing neuropathy (chloramphenicol, cisplatin, disulfiram, ethionamide, glutethimide, gold, hydralazine, iodoquinol, isoniazid, metronidazole, nitrofurantoin, phenytoin, ribavirin, vincristine). • Concurrent use with didanosine is not recommended. • Risk of pancreatitis is increased by concurrent use of other drugs causing pancreatitis (alcohol, asparaginase, azathioprine, estrogens, furosemide, methyldopa, nitrofurantoin, pentamidine, sulfonamides, tetracyclines, thiazide diuretics, valproates). • Aminoglycosides, amphotericin B. • Antacids decrease absorption. Drug-Food: • Food decreases absorption. Implementation -------------------------------------------------------------------------------• PO: Administer on an empty stomach, 1 hr before or 2 hr after meals for maximum absorption. Administer every 8 hr around the clock. › Antacids should not be administered concurrently with zalcitabine. Assessment --------------------------------------------------------------------------------

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• Assess patient for change in severity of symptoms of AIDS and for symptoms of opportunistic infections throughout therapy. • Monitor patient for signs and symptoms of peripheral neuropathy. Zalcitabine should be discontinued when moderate discomfort from numbness, tingling, burning, or pain of the extremities; loss of an Achilles tendon reflex; or any related symptoms occur, especially if symptoms last longer than 3 days and are bilateral. If zalcitabine is not stopped promptly, peripheral neuropathy may progress to severe pain and may be potentially irreversible. Neuropathy may progress despite discontinuation of zalcitabine but usually is slowly reversible with prompt discontinuation. If peripheral neuropathy improves to very mild symptoms, zalcitabine may be reintroduced at 50% of the regular dose. • Monitor patients for symptoms of pancreatitis (nausea, vomiting, abdominal pain) throughout therapy. If these symptoms or associated lab test signs occur, discontinue zalcitabine, as fatalities have occurred. Lab Test Considerations: • Monitor viral load and CD4 levels prior to and periodically throughout therapy. › Monitor serum amylase, lipase, triglyceride, and calcium throughout therapy. Rising serum amylase, lipase, triglyceride, and decreasing calcium levels may indicate pancreatitis. Assess baseline in patients with prior history of pancreatitis or increased amylase, those on parenteral nutrition, or those with history of alcohol abuse. Zalcitabine should be discontinued if serum amylase is elevated by 1.5–2 times the normal limits. › Monitor liver function. May cause elevated levels of AST, ALT, and alkaline phosphatase, which usually resolve following interruption of therapy. Lactic acidosis may occur with hepatic toxicity causing hepatic steatosis; may be fatal, especially in women. Patient/Family Teaching --------------------------------------------------------------------------------

• Instruct patient to take zalcitabine exactly as directed, around the clock. Emphasize the importance of compliance with therapy, not taking more than the prescribed amount, and not discontinuing without consulting health care professional. Missed doses should be taken as soon as remembered, unless almost time for next dose; patient should not double doses. • Inform patient that zalcitabine does not cure AIDS and does not reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom during sexual contact and avoid sharing needles or donating blood to prevent spreading the AIDS virus to others. • Instruct patient to notify health care professional promptly if signs of peripheral neuropathy or pancreatitis occur. • Advise women with childbearing potential to use a nonhormonal method of contraception throughout therapy.

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• Advise patient not to take other medications, including antacids, without consulting health care professional. • Emphasize the importance of regular follow-up exams and blood tests to determine progress and monitor for side effects. Lamivudine: Indications --------------------------------------------------------------------------------

• HIV infection (with other antiretrovirals). • Chronic hepatitis B infection. Unlabeled Uses: • Part of HIV-postexposure prophylaxis with zidovudine and indinavir. Action -------------------------------------------------------------------------------• After intracellular conversion to its active form (lamivudine-5-triphosphate), inhibits viral DNA synthesis by inhibiting the enzyme reverse transcriptase. Therapeutic Effects: • Slows the progression of HIV infection and decreases the occurrence of its sequelae. • Increases CD4 cell counts and decreases viral load. • Protection from liver damage caused by chronic hepatitis B infection; decreases viral load. Pharmacokinetics -------------------------------------------------------------------------------Absorption: Well absorbed after oral administration (86% in adults, 66% in infants and children). Distribution: Distributes into the extravascular space. Some penetration into CSF; remainder of distribution unknown. Metabolism/Excretion: Mostly excreted unchanged in urine; <5% metabolized by the liver. Half-life: Adults — 3.7 hr; children — 2 hr. Contraind./Precautions --------------------------------------------------------------------------------

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Contraindicated in: • Hypersensitivity. • Lactation. Use Cautiously in: • Impaired renal function (increased dosing interval/decreased dose recommended if CCr <50 ml/min). • Women, prolonged exposure, obesity, history of liver disease (increased risk of lactic acidosis and severe hepatomegaly with steatosis) . • Coinfection with hepatitis B (hepatitis may recur after discontinuation of lamivudine). • Geriatric patients (dosage reduction may be necessary). • Pregnancy or children <3 mo (safety not established). Exercise Extreme Caution in: • Pediatric patients with a history of pancreatitis (use only if no alternative). Adv. Reactions/Side Effects

Noted for combination of lamivudine plus zidovudine CNS: seizures, fatigue, headache , insomnia, malaise , depression, dizziness. Resp: cough. GI: hepatomegaly with steatosis, pancreatitis ( in pediatric patients), anorexia, diarrhea, nausea, vomiting, abdominal discomfort , abnormal liver function studies, dyspepsia . Derm: alopecia, erythema multiforme , rashes, urticaria. Endo: hyperglycemia. F and E: lactic acidosis. Hemat: anemia , neutropenia, pure red cell aplasia. MS: musculoskeletal pain, arthralgia, muscle weakness, myalgia , rhabdomyolysis. Neuro: neuropathy. Misc: hypersensitivity reactions including anaphylaxis and Stevens-Johnson syndrome . Interactions 2

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Drug-Drug: • Trimethoprim/sulfamethoxazole lamivudine blood levels (dosage alteration may be necessary in renal impairment). • risk of pancreatitis with concurrent use of other drugs causing pancreatitis. • risk of neuropathy with concurrent use of other drugs causing neuropathy. • Combination therapy with tenofovir and abacavir may lead to virologic nonresponse and should not be used. Interactions --------------------------------------------------------------------------------

Drug-Drug: • Trimethoprim/sulfamethoxazole lamivudine blood levels (dosage alteration may be necessary in renal impairment). • risk of pancreatitis with concurrent use of other drugs causing pancreatitis. • risk of neuropathy with concurrent use of other drugs causing neuropathy. • Combination therapy with tenofovir and abacavir may lead to virologic nonresponse and should not be used. Assessment -------------------------------------------------------------------------------• HIV: Assess patient for change in severity of symptoms of HIV infection and for symptoms of opportunistic infection during therapy. › Monitor patient for signs and symptoms of peripheral neuropathy (tingling, burning, numbness, or pain in hands or feet); may be difficult to differentiate from peripheral neuropathy of severe HIV disease. May require discontinuation of therapy. › Assess patient, especially pediatric patients, for signs of pancreatitis (nausea, vomiting, abdominal pain) periodically during therapy. May require discontinuation of therapy.

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• Chronic Hepatitis B Infection: Monitor signs of hepatitis (jaundice, fatigue, anorexia, pruritus) during therapy.

Lab Test Considerations: • › Monitor viral load and CD4 levels before and periodically during therapy. › Monitor serum amylase, lipase, and triglycerides periodically during therapy. Elevated serum levels may indicate pancreatitis and require discontinuation. › Monitor liver function. May cause elevated levels of AST, ALT, CPK, bilirubin, and alkaline phosphatase, which usually resolve after interruption of therapy. Lactic acidosis may occur with hepatic toxicity causing hepatic steatosis; may be fatal, especially in women. › May rarely cause neutropenia and anemia. Patient/Family Teaching --------------------------------------------------------------------------------

• Instruct patient to take lamivudine as directed, every 12 hr. Explain the difference between Epivir and Epivir-HBV to patients. Emphasize the importance of compliance with full course of therapy, not taking more than the prescribed amount, and not discontinuing without consulting health care professional. Take missed doses as soon as possible unless almost time for next dose. Do not double doses. Caution patient not to share medication with others. › Inform patient that lamivudine does not cure HIV disease or prevent associated or opportunistic infections. Lamivudine does not reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom during sexual contact and avoid sharing needles or donating blood to prevent spreading HIV to others. Advise patient that the long-term effects of lamivudine are unknown at this time. › Instruct patient to notify health care professional promptly if signs of peripheral neuropathy or pancreatitis occur. › Advise patient not to take other OTC or prescription medications or herbal products without consulting health care professional. › Emphasize the importance of regular follow-up exams and blood tests to determine progress and monitor for side effects.

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Ziagen: Indications --------------------------------------------------------------------------------

• Management of HIV infection (AIDS) in combination with other antiretrovirals (not with lamivudine and/or tenofovir). Pharmacokinetics -------------------------------------------------------------------------------Absorption: Rapidly and extensively (83%) absorbed. Distribution: Distributes into extravascular space and readily distributes into erythrocytes. Metabolism/Excretion: Mostly metabolized by the liver; 1.2% excreted unchanged in urine. Half-life: 1.5 hr. Contraind./Precautions -------------------------------------------------------------------------------Contraindicated in: • Hypersensitivity (rechallenge may be fatal). • Lactation: Breastfeeding not recommended for HIV-infected patients. Use Cautiously in: • OB: Safety not established. • Pedi: Safety not established in children <3 mo. Adv. Reactions/Side Effects --------------------------------------------------------------------------------

CNS: headache, insomnia . GI: hepatotoxicity , diarrhea, nausea , vomiting, anorexia . Derm: rashes. F and E: lactic acidosis .

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Misc: hypersensitivity reactions . Interactions -------------------------------------------------------------------------------Drug-Drug: • Alcohol increases blood levels. • May increase methadone metabolism in some patients; slight increase in methadone dosing may be needed. Implementation -------------------------------------------------------------------------------• PO: May be administered with or without food. Oral solution may be stored at room temperature or refrigerated; do not freeze. Assessment -------------------------------------------------------------------------------• Assess patient for change in severity of HIV symptoms and for symptoms of opportunistic infections throughout therapy. • Assess for signs of hypersensitivity reactions (fever; rash; gastrointestinal — nausea, vomiting, diarrhea, abdominal pain; constitutional — malaise, fatigue, achiness; respiratory — dyspnea, cough, pharyngitis). May also cause elevated liver function tests, increased creatine phosphokinase or creatinine, and lymphopenia. Discontinue abacavir at the first sign of hypersensitivity reaction. Do not restart abacavir following reaction; more severe symptoms may occur within hours and may include life-threatening hypotension and death. Symptoms usually resolve upon discontinuation. • May cause lactic acidosis and severe hepatomegaly with steatosis. Monitor patient for signs (increased serum lactate levels, elevated liver enzymes, liver enlargement on palpation). Therapy should be suspended if clinical or laboratory signs occur. Lab Test Considerations: • Monitor viral load and CD4 cell count regularly during therapy. › May cause serum glucose and triglyceride levels. Patient/Family Teaching --------------------------------------------------------------------------------

• Emphasize the importance of taking abacavir as directed. Must always be used in combination with other antiretroviral drugs. Do not take more than prescribed amount and do not stop taking without consulting health care professional. Take missed doses as soon as remembered; do not double doses. • Instruct patient not to share abacavir with others.

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• Inform patient that abacavir does not cure AIDS or prevent associated or opportunistic infections. Abacavir does not reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to use a condom, and avoid sharing needles or donating blood to prevent spreading the AIDS virus to others. Advise patient that the long-term effects of abacavir are unknown at this time. • Advise patient of potential for hypersensitivity reactions that may result in death. Instruct patient to discontinue abacavir and notify health care professional immediately if symptoms of hypersensitivity occur. Medication guide for patients should be dispensed with prescription. Advise patient to read it thoroughly with each refill. A warning card summarizing symptoms of abacavir hypersensitivity should be provided with each prescription; instruct patient to carry card at all times . • Emphasize the importance of regular follow-up exams and blood counts to determine progress and monitor for side effects. Zerit: Indications • HIV infection unresponsive or intolerant to conventional therapy. Action -------------------------------------------------------------------------------• Converted intracellularly to stavudine triphosphate, which inhibits viral DNA synthesis and replication. Therapeutic Effects: • Virustatic action against HIV. • Decreased viral load and increased cell count. • Not curative, but may slow progression of HIV infection and decrease the incidence and severity of its sequelae. Pharmacokinetics -------------------------------------------------------------------------------Absorption: Well absorbed after oral administration (78–80% bioavailability). XR formulation produces less fluctuation in levels. Distribution: Crosses the blood-brain barrier; enters RBCs and plasma equally. Metabolism/Excretion: Converted intracellularly to stavudine triphosphate, which is the active drug; 40% excreted unchanged in urine; 50% nonrenally eliminated. Half-life: Adults — 1–1.6 hr; children — 0.9–1.1 hr; adults with renal impairment — 4.8 hr; intracellular half-life — 3.5 hr. Contraind./Precautions --------------------------------------------------------------------------------

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Contraindicated in: • Hypersensitivity. Use Cautiously in: • Patients with a history of alcohol abuse. • Patients with a history of liver disease or hepatic impairment. • Renal impairment (dosage reduction and/or increased dosing interval recommended if CCr <50 ml/min). • History of peripheral neuropathy. • Pregnancy or lactation (safety not established; breastfeeding should be avoided by HIV-infected mothers because of transmission of the virus in breast milk; concurrent use with didanosine during pregnancy may increase the risk of fetal lactic acidosis). Adv. Reactions/Side Effects --------------------------------------------------------------------------------

CNS: headache, insomnia , weakness. GI: hepatic toxicity, pancreatitis, anorexia , diarrhea. F and E: lactic acidosis. Hemat: anemia. MS: arthralgia, myalgia. Neuro: peripheral neuropathy . Interactions -------------------------------------------------------------------------------Drug-Drug: • Use cautiously withdrugs causing peripheral neuropathy (chloramphenicol, cisplatin, dapsone, didanosine, ethambutol, ethionamide, hydralazine, isoniazid, lithium, metronidazole, nitrofurantoin, phenytoin, vincristine, or zalcitabine). • Concurrent use with didanosine may risk of pancreatitis. • Concurrent use with zidovudine is not recommended because of possible antiretroviral antagonism. Implementation --------------------------------------------------------------------------------

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• PO: May be administered without regard to food. › Shake solution vigorously before administration. Keep refrigerated; discard unused portion after 30 days. › XR capsules can be opened and mixed with 2 tbsp of yogurt or applesauce. Entire contents should be swallowed immediately. Advise patient not to chew or crush beads while swallowing. Assessment -------------------------------------------------------------------------------• Assess patient for change in severity of symptoms of HIV infection and for symptoms of opportunistic infection during therapy. • Monitor patient for signs and symptoms of peripheral neuropathy (tingling, burning, numbness, or pain in hands or feet); may be difficult to differentiate from peripheral neuropathy of severe HIV disease or lactic acidosis. May resolve if stavudine therapy is discontinued promptly or may temporarily worsen after discontinuation of therapy. If symptoms resolve completely, stavudine therapy may resume at 50% of the regular dose. • Assess patient for signs of pancreatitis (nausea, vomiting, abdominal pain) periodically throughout therapy. Occurs rarely, but may require discontinuation of therapy. Lab Test Considerations: • Monitor viral load CD4 counts before and regularly during therapy. › Monitor liver function. May cause levels of AST, ALT, and alkaline phosphatase, which usually resolve after interruption of therapy. Lactic acidosis may occur with hepatic toxicity causing hepatic steatosis; may be fatal, especially in women. › May cause serum amylase and lipase levels.

Patient/Family Teaching -------------------------------------------------------------------------------• Instruct patient to take stavudine as directed. Emphasize the importance of compliance with full course of therapy, not taking more than the prescribed amount, and not discontinuing without consulting health care professional. Take missed doses as soon as possible unless almost time for next dose. Do not double doses. Caution patient not to share medication with others. • Inform patient that stavudine does not cure HIV disease and does not reduce the risk of transmission of HIV to others through sexual contact or blood contamination. Caution patient to avoid sexual contact or to use a condom, and to avoid sharing needles or donating blood to prevent spreading HIV to others. • Instruct patient to notify health care professional promptly if signs of lactic acidosis (unexplained weight loss, abdominal discomfort, nausea, vomiting, fatigue, dyspnea, motor weakness), peripheral neuropathy, or pancreatitis occur. • Advise patient not to take other OTC or prescription medications without consulting health care professional. • Emphasize the importance of regular follow-up exams and blood tests to determine progress and monitor for side effects.

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THERE ARE MORE MEDS I WILL ADD LATER!!!!

NURSING INTERVENTIONS: Administer IV fluids are ordered Administer O2 Encourage Turn Cough and DB and use of incentive spirometer Assess Respiratory and neurologic status and fluid balance Montior and record VS and I/O laboratory studies daily weight and pulse ox Administer TPN as ordered Administer medications as prescribed Encourage pt to express feelings about dx Maintain activity as tolerated provide rest periods Allay the pts anxiety and provide emotional support Provide skin and mouth care Monitor for opportunistic infections Individualize home care instructions TEACH about disorder and treatment Following medication use and aware of medications s/e Refrain from donating blood Avoid ETOH and Drugs Use Condoms during sex Contact community resources Comply with medical followup. COMPLICATIONS: Pneumocystis carinnii pneumonia Cryptococcal meningitis Burkitts lymphoma Encephalopathy Depression Herpes simplex Cytomegalovirus infection EBV Oral and esophageal candidiasis Kaposi’s sarcoma Toxoplasmosis Mycobacterium avium intracellular infection Neuropathies Myopathies

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