Antiretroviral Therapy for HIV Infected Adult

Standard Nurse Protocols for Antiretroviral Therapy in HIV Infected Adult

 
DEFINITION
 
Antiretroviral therapy refers to a combination of medications used to treat HIV infection. These drug combinations are commonly called antiretroviral therapy (ART). Currently, there are six classes of these drugs approved by the Food and Drug Administration (FDA): nucleoside and nucleotide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, fusion inhibitors, Chemokine receptor 5 antagonists, and integrase strand transfer inhibitors. Since the mid-1990s, when studies demonstrated the superiority of three-drug regimens over single or dual drug regimens, national guidelines have mandated the use of three or more drugs in combination to treat HIV infection.
Once an ART regimen is initiated, it is generally continued indefinitely unless the patient experiences medication intolerance, severe side effects, adverse reactions, or treatment failure.
 
SUBJECTIVE
 
·
Currently taking an appropriate ART regimen.
Reports medication adherence and a desire to continue current ART regimen.
Absence of adverse reactions or significant side effects to antiretroviral medications.
·         Absence of allergies to antiretroviral medications.
·         Obtain a complete medication profile to determine whether or not there are any clinically significant drug-drug interactions.
NOTE: Medication profiles should include over-the-counter (OTC) medications, herbals, vitamins, and prescription medications.
OBJECTIVE
            CD4 count and HIV viral load history.
·                     Resistance testing history.
·        No evidence of virologic or immunologic failure as defined in the Department of Health and Human Services (DHHS) antiretroviral guidelines.
·
The most recent complete blood count (CBC) with differential and
·         platelet count, chemistry profile including liver and renal functions,
·         and lipid profile are within acceptable values.
·        No evidence of past or current resistance to the ART regimen.
·        If ordering abacavir, no evidence of Human Leukocyte Antigen – B*5701 (HLA-B*5701) positive test result.
·         If ordering a CCR5 antagonist (e.g., maraviroc), no evidence of Chemokine receptor 4 (CXCR4) or dual/mixed coreceptor tropism.
 
ASSESSMENT
 
No contraindications for continuation of antiretroviral regimen.
PLAN
 
 
 DIAGNOSTIC STUDIES
 
·
 Repeat CD4 count and HIV viral load, if indicated.
 Repeat CBC with differentials, chemistry profile including liver and renal function,
lipid profile, if indicated, and pregnancy test for females if indicated.
 
THERAPEUTIC
 
·
Order one-month supply of each antiretroviral medication the patient is currently taking. See the latest DHHS antiretroviral guidelines, “Guidelines for the Use of Antiretroviral Agents in HIV- 1 Infected Adults and Adolescents,” for recommendations including antiretroviral regimens, agent formulations and dosing, adverse events, and drug-drug interactions.
·        Review the patient’s current medication list for possible drug-drug interactions. Include prescription medications, OTC drugs/products, and nutritional or herbal supplements.
 
PATIENT
EDUCATION/COUNSELING
 
·
Review current drug regimen including drug storage, dose, route of administration, schedule, food requirements or
restrictions, side effects, potential drug-drug interactions, and follow-up monitoring.
·        Provide measures to promote adherence such as written medication schedules and pillboxes.
·
Discourage patient from stopping ART regimen without consulting provider first.
·
Instruct patient to return for scheduled appointment. Stress that failure to keep appointments may result in discontinuation of medications.
·
Ask patient to immediately report adverse drug

reactions, side effects or other changes in health that he/she feels are
important to his/her care provider.
 
Instruct patient that HIV medications,

especially protease inhibitors and non-nucleoside reverse transcriptase
inhibitors, have a high potential for significant drug interactions.
·
Ask patient to check with his/her pharmacist or

provider about interactions before taking a new medication, nutritional or
herbal supplement, or OTC drug/product.
·
Request that the patient not “borrow”

medications from friends or family or obtain prescription drugs outside the
care of his/her physician (e.g., erectile dysfunction agents).
·
Instruct patient to bring all medications,

nutritional or herbal supplements, and OTC drugs/products to his/her medical
appointments.
FOLLOW-UP
 
Return appointment with provider in 2-4 weeks.
 
CONSULTATION/REFERRAL
 
 
·
Refer the following to the physician:
o
Non-adherent patients.
o
ART regimens that do not follow the latest DHHS
treatment guidelines.
o
Suspected treatment failure.
o
Adverse reactions to ART or severe/significant
side effects.
o
Results of drug resistance testing.
o
Patients desiring pregnancy or pregnant.
·
Consult with the physician concerning any abnormal lab results.
Consult with the physician concerning instructions for discontinuing ART regimens.
Consult with the physician concerning antiretroviral therapy in patients with renal or hepatic insufficiency.
Consult with the physician if a patient on an abacavir-containing regimen is HLA-B*5701 positive
Consult with the physician if a patient on a CCR5 antagonist has CXCR4 or dual/mixed coreceptor tropism.
         Reference :  http://www.aidsinfo.nih.gov/.

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