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Learn to recognize and manage common side effects of ARVs to ensure proper care for patients in Vietnam. Understand symptoms, management strategies, and when to seek medical help.
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Side Effects of Anti-retroviral Therapy HAIVN Harvard Medical School AIDS Initiative in Vietnam
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
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
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
Peripheral Neuropathy: Symptoms • This is a common side effect of d4T • Symptoms: • Pain or tingling in hands and feet • Stocking and glove distribution • Symmetrical
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
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
Pancreatitis: Management • Must STOP the medication • Patients should come to clinic • May need to be hospitalized
Nausea and Vomiting: Symptoms • Very common at start of therapy • Often improves with time: • Provide reassurance
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
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
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)
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
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
Serious Side Effects: Management • Closely monitor patients to recognize symptoms of serious side effects • May need to swap for D4T or TDF
Rash: Symptoms • Rash caused by NVP usually appears 2-6 first wks of treatment, but could be later
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.
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
Symptoms that Indicate Serious Rash • Skin necrosis • Blisters or epidermal detachment • Mucous membrane erosions • Urticaria • Swelling of tongue • Confluent erythema • Facial edema or central facial involvement • Skin pain • Palpable purpura
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
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
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)
Sleep Disturbances:Symptoms • Difficulty sleeping • May have very vivid dreams – sometimes nightmares • Usually goes away in a few weeks
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
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
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
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
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
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
Side Effects ofLopinavir/r (LPV/r, Kaletra) • GI intolerance: • nausea, vomiting • diarrhea • Hyperglycemia (insulin resistance) • Fat redistribution and abnormal lipids • Occasional rash and headace
Side Effects of Lopinavir/r: Management (1) If patients developsvomiting 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
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
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
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)
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