ARV Complications and Management

1. ARV Complications and Management Iv�n Mel�ndez Rivera, M.D. F.A.A.F.P. A.A.H.I.V.S.

3. Initial Medical Evaluation Baseline Physical Condition Neurologic Function

4. Initial Medical Evaluation Laboratories CBC & Diff., FBS Liver Profile, Hepatitis profile Lipid Profile, Renal function Current Medications Co-morbid conditions Over the counter Alternative Medicine Products Intravenous or recreational Drug Use

5. Initial Medical Evaluation Child bearing potential Evaluate for adherence Assess patient knowledge regarding medications side effect

6. Nucleoside and Nucleotide Reverse Transcriptase Inhibitors

7. Nucleoside/Nucleotide 7 FDA approved Nucleoside 1 FDA approved Nucleotide 4 fixed dose combination tablets

8. Common NRTI�s Side Effects Mitochondrial Toxicity Due to NA inhibition of mitochondrial DNA polymerase responsible for mitochondrial DNA synthesis. Responsible for lactic acidosis , hepatic steatosis, myopathy, pancreatitis, peripheral neuropathy and lipoatrophy. Relative Inhibitory Potency: ddC>ddI>d4T>ZDV>3TC=ABC=TDF

9. Common NRTI�s Side Effects Lactic Acidosis and Hepatic Steatosis Asymptomatic hyperlactatemia Symptomatic hyperlactatemia Asymptomatic hyperlactemia: exist in 21% of patient on Nucleoside Analogue therapy. Not predictive of lactic acidosis. Routine monitoring of level not recommended. Symptomatic hyperlactatemia: elevated lactate with associated symptoms such as gastrointestinal, dyspnea and weight loss. Some cases present ascending neuromuscular weakness (ANMW) mimicking Guillain Barre syndrome. New label warning was placed on d4T, alerting physicians to recognize and appropriately manage early signs of hyperlactatemia.Asymptomatic hyperlactemia: exist in 21% of patient on Nucleoside Analogue therapy. Not predictive of lactic acidosis. Routine monitoring of level not recommended. Symptomatic hyperlactatemia: elevated lactate with associated symptoms such as gastrointestinal, dyspnea and weight loss. Some cases present ascending neuromuscular weakness (ANMW) mimicking Guillain Barre syndrome. New label warning was placed on d4T, alerting physicians to recognize and appropriately manage early signs of hyperlactatemia.

10. Common NRTI�s Side Effects Lactic acidosis syndrome (LAS) Severe symptomatic Hyperlactatemia Metabolic acidosis Hepatomegaly (Hepatic steatosis) Steatosis Fatalities, late pregnancy, specially d4T & ddI combination

11. Common NRTI�s Side Effects Lactic acidosis syndrome (LAS) Risk Factors Female Obesity Numbers of Nucleoside Analogues used ddI +/or d4T, AZT, ribavirin, or hydroxyurea use Laboratories Lactate levels >2-5 mmol/L (>10mmol/L Emergency) Anion Gap (>16) ? AST, ALT, LDH, amylase, lipase, CPK ? serum albumin, pH or bicarbonate

12. Common NRTI�s Side Effects Lactic Acidosis Treatment IV fluid�s D/C ARV Bicarbonate: correct acidemia Riboflavin 50 mg/day, thiamine, coenzyme Q Antiretroviral rechallenge Insufficient data First document normal lactate level X 3 mos. Consider ABC, 3TC, FTC, or TDF regimen

13. Common NRTI�s Side Effects Lipodystrophy (Fat Redistribution) Advisory warning is now included in labeling for ALL antiretrovirals Accumulation abdomen (central obesity) dorsocervical area (Buffalo Hump) Breast Loss Face Extremities Buttocks Metabolic disturbance Dyslipidemia and Insulin Resistance

14. Fat Redistribution

15. Fat Redistribution

16. Common NRTI�s Side Effects Lipodystrophy Risk Factors >40 years Base BMI and changes (>2kg/m2) Years infected Effectiveness of Viral suppression Baseline CD4 (<100) and time to change White Race

17. Common NRTI�s Side Effects Lipodystrophy Non Pharmacologic Treatment Life style change Low fat diet, Aerobic exercise Surgery Lipectomy, Liposuction, Facial Implants Injection of inert substance (i.e., Sculptra) Pharmacologic Treatment Switching Antiretroviral therapy Growth Hormone Testosterone replacement or Anabolic steroids, Dietary supplements

18. Zidovudine (ZDV) Gastrointestinal (nausea, vomiting, anorexia) Headache Malaise Myopathy Bone Marrow Toxicity Anemia Neutropenia Macrocytosis (Inc. MCV,MCH) Hyperpigmentation (nail bed, mouth) Macrocytosis is and indirect form to determinate if patient is taking the medication Macrocytosis is and indirect form to determinate if patient is taking the medication

19. Staduvine (d4T) Distal Symmetric Polyneuropathy Numbness or burning dysesthesia of the distal extremities Sharp Shooting pain Continuous severe burning Depressed ankle reflexes Abnormal vibratory, pinprick and cold sensation Dose related Hyperlipidemia

20. Lamivudine (3TC) Generally well tolerated with a rare occurrence of serious or non-serious side effects.

21. Emtricitabine Rash Hyperpigmentation of palms/soles 6% of patients > Black and Hispanic patients

22. Didanosine (ddI) Pancreatitis Increased risk when used with d4T or pentamidine Distal Symmetrical Polyneuropathy

23. Tenofovir Renal Abnormalities (Elevated creatinine and Hypophosphatemia) Dose reduce when CrCl<50 ml/minute Osteomalacia

24. Abacavir (ABC) Hypersensitivity Reaction Reported in up to 8% of patients 90% Appear within first 6 weeks (~ 11 days) Symptoms include: Fever, skin rash (70%), GI symptoms (nausea, vomiting, diarrhea, abdominal Pain) Headache, malaise, myalgias Fatigue Respiratory (pharyngitis, cough, dyspnea) ?CPK, ? LFT, lymphopenia

25. ABC Hypersensitivity True ABC Hypersensitivity will experience worsening symptoms with each dose ABC Hypersensitivity Registry: 800-270-0425 Note: Ask you patient how he felt 2 hours after take the medication. If worsening is most be the medication. Prevent discontinuation of medication until you know is cause by them. Rechalent never recommended even when you discover symptom was not cause by medicationNote: Ask you patient how he felt 2 hours after take the medication. If worsening is most be the medication. Prevent discontinuation of medication until you know is cause by them. Rechalent never recommended even when you discover symptom was not cause by medication

26. Zalcitabine (ddC) Oral/ esophageal ulcers 3-4% treated patients Distal Symmetrical Polyneuropathy Perioral paresthesia Pancreatitis

27. Non Nucleoside Reverse Transcriptase Inhibitors

28. Common NNRTI Side Effects RASH Occurs during first 6 weeks or later in the treatment Presentation Diffuse maculopapular, erythematous and pruritic. If accompanied by fever, blistering, oral lesions, conjunctivitis, swelling, muscle or joint aches could be Stevens-Johnson syndrome

29. Common NNRTI�s Side Effects RASH Treatment Most of them resolve with d/c medication Pharmacologic Diphenhydramine, hydroxyzine Corticosteroids (worsening nevirapine rash)

30. Efavirenz Dizziness Impaired Concentration Sleep disturbance Early Insomnia (r/o anxiety) Terminal Insomnia � Intermittent sleep (r/o depression) Drowsiness/Somnolence Teratogenic

31. Efavirenz Abnormal Dreams Anxiety/ Agitation/ Nervousness Depression Symptoms resolve over time

32. Nevirapine Hepatotoxicity Asymptomatic AST/ALT elevations >5 times upper normal limit �Black Box� fatal hepatotoxicity including fulminant and cholestatic hepatitis, hepatic necrosis and hepatic failure Hepatotoxicity Symptoms Non-specific flu like illness, fatigue, malaise, anorexia, nausea, jaundice Might discuss here the warning in pregnancyMight discuss here the warning in pregnancy

33. Delavirdine Multiple drug-drug interactions Fatigue

34. PROTEASE INHIBITORS

35. Common Protease Inhibitor Side Effects Lipodystrophy Fat Maldistribution Hepatotoxicity (?? AST,ALT,GGT?)

36. Common Protease Inhibitor Side Effects Hyperglycemia 3-17% on PI therapy at 60 days Causes: Peripheral and hepatic insulin resistance Glut 4 deficiency Reduction or inhibition of gluconeogenesis Family history of Diabetes Medications (pentamidine, Megace)

37. Insulin Resistance Slide 14 Hyperglycemia in Type 2 Diabetes The hyperglycemic state in type 2 diabetes is due to 3 related metabolicabnormalities Increased glucose production by the liver Reduced insulin secretion by the pancreas Insulin resistance in the peripheral tissues Pharmacologic agents that improve insulin action and effectively restore the balance between hepatic glucose production and disposal of glucose in the peripheral tissues can benefit individuals with diabetes Saltiel AR, Olefsky JM. Diabetes. 1996;45:1661 Slide 14 Hyperglycemia in Type 2 Diabetes The hyperglycemic state in type 2 diabetes is due to 3 related metabolicabnormalities Increased glucose production by the liver Reduced insulin secretion by the pancreas Insulin resistance in the peripheral tissues Pharmacologic agents that improve insulin action and effectively restore the balance between hepatic glucose production and disposal of glucose in the peripheral tissues can benefit individuals with diabetes Saltiel AR, Olefsky JM. Diabetes. 1996;45:1661

38. Common Protease Inhibitors Side Effects Hyperglycemia Treatment Non Pharmacologic Exercise/weight loss Adequate nutrition Pharmacologic Insulin sensitization drugs: metformin, rosiglitazones Insulin Switch ART Nothing substitute God Nutrition and exercise Advice not use �crash diets� due to increase muscle mass loss and increase fat deposit Exercise most be structured: 15 minutes cardiovascular and 20-30 minutes resistance. Excessive cardiovascular exercise can accelerate lipodystrophy changes. Medication: Rosiglitazones are the medication of choice to start and always �Star low go slow� 2mg daily the change to 4mg daily. If not enough reduction on glucose lever add metformin 500mg-1,000mg daily. Keep in mind the drugs interaction (metformin whit ddI and d4T increase risk of Lactic Acidosis) and side effect (rosiglitazones increase triglycerides and cause leg edema) Some studies demonstrated Indinavir alone cause increase in glucose levels in healthy volunteers. For that reason prevent the use in person with high risk of hyperglycemia. Ritonavir also have high incidence of hyperglycemia for that reason unboosted version of PI can be use.Nothing substitute God Nutrition and exercise Advice not use �crash diets� due to increase muscle mass loss and increase fat deposit Exercise most be structured: 15 minutes cardiovascular and 20-30 minutes resistance. Excessive cardiovascular exercise can accelerate lipodystrophy changes. Medication: Rosiglitazones are the medication of choice to start and always �Star low go slow� 2mg daily the change to 4mg daily. If not enough reduction on glucose lever add metformin 500mg-1,000mg daily. Keep in mind the drugs interaction (metformin whit ddI and d4T increase risk of Lactic Acidosis) and side effect (rosiglitazones increase triglycerides and cause leg edema) Some studies demonstrated Indinavir alone cause increase in glucose levels in healthy volunteers. For that reason prevent the use in person with high risk of hyperglycemia. Ritonavir also have high incidence of hyperglycemia for that reason unboosted version of PI can be use.

39. Site of action of oral hypoglycemic drugs Slide 37 Therapy for Type 2 Diabetes: Sites of Action Our current armamentarium of OADs used to treat type 2 diabetes attempt to control hyperglycemia at different points within the pathway of the glucose cycle from reducing carbohydrate metabolism in the gut, to increasing insulin production in the pancreas, or by increasing glucose uptake in tissue, or lowering hepatic glucose production between meals Clearly, combination therapy using OADs to control glucose regulation at distinctive points within the glucose pathway can help reduce FPG and PPG levels Davis SN. Postgrad Med. 2000;16Slide 37 Therapy for Type 2 Diabetes: Sites of Action Our current armamentarium of OADs used to treat type 2 diabetes attempt to control hyperglycemia at different points within the pathway of the glucose cycle from reducing carbohydrate metabolism in the gut, to increasing insulin production in the pancreas, or by increasing glucose uptake in tissue, or lowering hepatic glucose production between meals Clearly, combination therapy using OADs to control glucose regulation at distinctive points within the glucose pathway can help reduce FPG and PPG levels Davis SN. Postgrad Med. 2000;16

40. Common Protease Inhibitors Side Effects Hyperlipidemia Increase Chol., LDL-C, Triglycerides Decrease HDL-C Risk factors Male >40 smoker family history of diabetes Hypertensive Vascular Disease HTVD, Please spell out. HTVD, Please spell out.

41. Common Protease Inhibitors Side Effects Hyperlipidemia Treatment Pharmacologic HMG-CoA Reductase (pravastatin, rosuvastatin or atorvastatin only) Fibrates Switching ART Non pharmacologic Nutrition and exercise Smoking cessation Studies only made with pravastatin because do not interact with the cytocrome in the liver but is a slow Cholesterol reducer. Atrovastatine partially metabolize in cytocrome P450 and some studies don�t show interaction whit PI and is a better cholesterol reductor. Rosuvastatin don�t have studies but do not use cytocrome P450 preventing interactions. Always start with the lower dose Pravastatine 20mg, Atrovastatine 10mg, Rosuvastatine 5mg. Ezetimibe 10mg/daily as adjuvant therapy. Fibrates: Fenofibrate 160mg daily if renal impairment start with 54mg/day. Gemfibrozil not recommended Niacine not recommended due to impair medication absorption and increase risk of hepatotoxicityStudies only made with pravastatin because do not interact with the cytocrome in the liver but is a slow Cholesterol reducer. Atrovastatine partially metabolize in cytocrome P450 and some studies don�t show interaction whit PI and is a better cholesterol reductor. Rosuvastatin don�t have studies but do not use cytocrome P450 preventing interactions. Always start with the lower dose Pravastatine 20mg, Atrovastatine 10mg, Rosuvastatine 5mg. Ezetimibe 10mg/daily as adjuvant therapy. Fibrates: Fenofibrate 160mg daily if renal impairment start with 54mg/day. Gemfibrozil not recommended Niacine not recommended due to impair medication absorption and increase risk of hepatotoxicity

42. Common Protease Inhibitors Side Effects Increased Bleeding Episodes in Hemophiliacs Etiology uncertain Occurs in the first month of therapy Treatment Constant monitoring of prothombin time Additional coagulation factor if needed Switching ART PT & PTT and the beginning and every 2 weeks for the first 2 monthsPT & PTT and the beginning and every 2 weeks for the first 2 months

43. Common Protease Inhibitors Side Effects Osteopenia and Osteoporosis Decrease in bone mineral density Most common site is femoral head Risk factors Hyperlipidemia, alcohol abuse, SLE, chronic steroid use, hypercoagulable states, post menopausal women Sings and Symptoms Limping Persistent pain in related area

44. Common Protease Inhibitors Side Effects Osteopenia and Osteoporosis Evaluation: CT or MRI Treatment Non pharmacologic Weight-bearing exercise Adequate intake of Calcium and Vit. D Surgery Pharmacologic Biphosphonates, raloxifene or calcitonin Always use Biphosphonate with Calcium Calcium 2 to 2.4 grams dailyAlways use Biphosphonate with Calcium Calcium 2 to 2.4 grams daily

45. Common Protease Inhibitors Side Effects GI Intolerance (Nausea, Vomiting, Diarrhea) Treatment: Non pharmacologic Small frequent meals Avoid spicy or greasy food BRAT diet for diarrhea Take pills with food Adequate fluid intake Honey (5ml) with pills( careful when <200 CD4) Calcium 500mg bid Banana, Rice, Apple, Toast Banana, Rice, Apple, Toast

46. Common Protease Inhibitors Side Effects GI Intolerance Treatment: Pharmacologic Antiemetic agents: metoclopramide, phenothiazine class (promethazine), dronabinol Anti-diarrhea: loperamide, oat bran Folic acid 1-2mg daily Switch ART Diarrhea: 1. Calcium 500mg bid 2. Folic acid 1mg daily or 1mg bid 3. loperamide 2mg daily Nauseas: 1.Honey 2. Take always with food 3.metocloporamide 10mg tid (if no diarrhea) 4.promethazine 12.5mg qd-tid 5.dronabinol 2.5mg po bid, before lunch and dinner Diarrhea: 1. Calcium 500mg bid 2. Folic acid 1mg daily or 1mg bid 3. loperamide 2mg daily Nauseas: 1.Honey 2. Take always with food 3.metocloporamide 10mg tid (if no diarrhea) 4.promethazine 12.5mg qd-tid 5.dronabinol 2.5mg po bid, before lunch and dinner

47. Amprenavir (APV) or Fosamprenavir (fAPV) Use with caution in sulfonamide allergic patients Amprenavir, not Fosamprenavir, contains high dose of Vitamin E Nausea is the biggest SE Less effect on lipids unless RTV boosted

48. Atazanavir PR interval and QTc prolongation Look for drug interaction (PPI, CCB) Does not cause hyperlipidemia Asymptomatic elevation indirect (unconjugated) Bilirubin (5%) Inhibition of UDP-glucuronosyl transferase (UGT) Drugs Interaction Proton Pump Inhibitors Calcium Channel Bloquers Clarithromycin Rimfampin Drugs Interaction Proton Pump Inhibitors Calcium Channel Bloquers Clarithromycin Rimfampin

49. Overview of Bilirubin Production and Metabolism

50. Indinavir (IDV) Nephrolithiasis 12.4% cumulative frequency increase with exposure to IDV Monitoring for: crystalluria, hematuria, leukocyturia Repeat U/A q 3 month at leastRepeat U/A q 3 month at least

51. Indinavir (IDV) Skin Changes Rash, dry skin, ingrown nails Hyperbilirubinemia Increase of non conjugated (indirect) bilirubin Ingrown nails � if more than 2 times happens change the medicationIngrown nails � if more than 2 times happens change the medication

52. Lopinavir/ritonavir (LPV/r) Oral solution contains 42% alcohol Pancreatitis Prevent the use of other concomitant drugs who increase the risk of pancreatitis

53. Nelfinavir (NFV) Avoid in persons with phenylketonuria Diarrhea is the most common SE

54. Ritonavir (RTV) Use as a solo PI not recommended Pancreatitis Paresthesia

55. Saquinavir (SQV) Taste alteration

56. ENTRY INHIBITOR

57. Enfuvertide (T-20) Reactions on the skin where Fuzeon is injected can include itching, swelling, redness, pain or tenderness, hardened skin, or bumps. More rarely: serious allergic reactions Treatment Non pharmacologic: Massage 5 min. post injection Pharmacologic: Low potency topical steroid Massage can be manual or with a small massage machine Hydrocortisone 1%Massage can be manual or with a small massage machine Hydrocortisone 1%

58. Management of Side Effects

59. Anxiety/Agitation/Nervousness Pharmacologic Anxiolytics like lorazepam, clonazepam Low dose neuroleptic medication (formal psychiatric evaluation needed) Lorazepam .5mg bid medium half life Clonazepam .25mg bid Long half life: opportunity to use as PRN, specially in patient who say �don�t want to be addicted to meds� but carefull with dose addition. Lorazepam .5mg bid medium half life Clonazepam .25mg bid Long half life: opportunity to use as PRN, specially in patient who say �don�t want to be addicted to meds� but carefull with dose addition.

60. Anxiety/Agitation/Nervousness Non pharmacologic Evaluate for other causes including psychiatric or substance use Avoid: stimulant food (coffee, chocolate, nicotine) OTC, substance use Stress relieving activities such as exercise, yoga, meditation

61. Bone Marrow Toxicity Pharmacologic If Hg<7.5 dose interruption Blood Transfusion Epoetin alfa for anemia G-CSF or GM-CSF for neutropenia Epoetin 100-300units/kg s/c 3 times a week GM-CSF (sargramostim) Epoetin 100-300units/kg s/c 3 times a week GM-CSF (sargramostim)

62. Distal Symmetrical Polyneuropathy Pharmacological Decrease d4T or ddI dose, if persist D/C Non Opioid , Weak opioid, Strong opioid Tricyclic Antidepressants (e.g. amitriptyline) Anticonvulsant: gabapentin, carbamazepine Topical Capsaicin Try all alternative medicine first B-12: 1cc intramuscular weekly to 3 times a week Intranasal and po medication not equally efective Acupunture will need at leat 5 treatments Medication 1. If pain is occasional use NSAID (naprosen 500mg bid) 2. Persistent Pain: Amitriptyline 25-100mg hs 3.Gabapentin 300mg tid to 600mg tid 4.Carbamazepine 100mg bid 5.Weak opioid: Drugs Combination Acetaminophen with codeine 1 tab q 4-6 hrs. 6.Strong opiod: morphine, MS Contin 30mg q 12 hrs. Watch for constipation 7.Fentanyl Duragesic patches 25-75mcg patch q 72hrs. Excellent for pill burn Try all alternative medicine first B-12: 1cc intramuscular weekly to 3 times a week Intranasal and po medication not equally efective Acupunture will need at leat 5 treatments Medication 1. If pain is occasional use NSAID (naprosen 500mg bid) 2. Persistent Pain: Amitriptyline 25-100mg hs 3.Gabapentin 300mg tid to 600mg tid 4.Carbamazepine 100mg bid 5.Weak opioid: Drugs Combination Acetaminophen with codeine 1 tab q 4-6 hrs. 6.Strong opiod: morphine, MS Contin 30mg q 12 hrs. Watch for constipation 7.Fentanyl Duragesic patches 25-75mcg patch q 72hrs. Excellent for pill burn

63. Distal Symmetrical Polyneuropathy Non pharmacologic B-12 Vitamin (Intramuscular) Acupuncture and massage Identify another causes (alcohol, diabetes) and treat

64. Dizziness Pharmacologic Antivert or Dramamine Non Pharmacologic Take ARV medication at bed time Or 12-15 hr before need to be functional Evaluate for ENT disorders Antivert 12.5mg qd-tidAntivert 12.5mg qd-tid

65. Fatigue Non Pharmacologic Nutrition Exercise DHEA Sleep hygiene Determine co morbid conditions and Tx. Pharmacologic Hormone replacement: Testosterone Growth Hormone Important Nutritionist evaluation to determine increase or reduce simple CHO (If catabolic state is extremely high need to add high energy food every 4 hours) Exercise: low cardiovascular (walk 20 minutes whit adequate oxygenation) DHEA: 25-75 mg daily Sleep: 6-8 hours. No more than 10 hours because the body will felt with more fatigue Co morbid conditions Anemia Malignancy Hepatitis B and C Active Hypogonadims Depo-testoterone: male: 100mg IM q wk x 10 wks rest 8 wks and can repeat the cycle Female: 25mg IM q wk x 10 wks rest 8 wks and can repeat the cycle Growth Hormone (Serostim) >55 kg=6mg SC qhs 45-55 kg = 5mg SC qhs 35-45 kg = 4mg SC qhs <35 kg = 0.1mg/kg SC qhs Important Nutritionist evaluation to determine increase or reduce simple CHO (If catabolic state is extremely high need to add high energy food every 4 hours) Exercise: low cardiovascular (walk 20 minutes whit adequate oxygenation) DHEA: 25-75 mg daily Sleep: 6-8 hours. No more than 10 hours because the body will felt with more fatigue Co morbid conditions Anemia Malignancy Hepatitis B and C Active Hypogonadims Depo-testoterone: male: 100mg IM q wk x 10 wks rest 8 wks and can repeat the cycle Female: 25mg IM q wk x 10 wks rest 8 wks and can repeat the cycle Growth Hormone (Serostim) >55 kg=6mg SC qhs 45-55 kg = 5mg SC qhs 35-45 kg = 4mg SC qhs <35 kg = 0.1mg/kg SC qhs

66. GI Intolerance Pharmacologic Antiemetic Non Pharmacologic Taking medication with food Honey 5ml before pills Careful in patient with less than 200 CD4

67. Headaches, Malaise Pharmacologic Analgesic (e.g. acetaminophen or NSAID) Non- Pharmacologic Plenty of water (>2 liter/day) Sleep Hygiene (6-8 hours/night) Naprosen sodium 225mg bidNaprosen sodium 225mg bid

68. Hepatotoxicity Non pharmacologic Monitor liver function test carefully during the first 16 weeks of treatment Monitor patient for symptoms suggestive of hepatitis including liver tenderness or hepatomegaly Check Baseline LFT and Hepatitis status Start medication in lower dose (nevirapine only) Pharmacologic Milk thistle Switching ART Every 2 weeks x 2 months then monthly x 2 then q 3 months Milk thistle 100-200mg po tid of standardized extract with 70-80% silymarinEvery 2 weeks x 2 months then monthly x 2 then q 3 months Milk thistle 100-200mg po tid of standardized extract with 70-80% silymarin

69. Hyperbilirubinemia Non Pharmacologic Plenty of water Sun exposure Pharmacologic None Do not reduce dose Switch ART (D/C ATV) Sun exposure: 10-20 minutes dailySun exposure: 10-20 minutes daily

70. Hypersensitivity Reaction Pharmacologic D/C ABC IV Fluids and Vasopressors No pharmacologic agents have been identified for prevention Non Pharmacologic Educate patient about signs and symptoms Patient Warning Card Imp.: Documented education given to patient in the medical recordImp.: Documented education given to patient in the medical record

71. Impaired Concentration Non Pharmacologic Avoid multitasking situations Utilize appointment books, calendar, note pads Gingko biloba Pharmacologic No proven medication Anecdotic pharmacological use of Coffee, Ritalin, Strattera, Cylert (all in low dose) Gingko biloba: 40mg po tid (varies due to brands) Carefully with bleedingAnecdotic pharmacological use of Coffee, Ritalin, Strattera, Cylert (all in low dose) Gingko biloba: 40mg po tid (varies due to brands) Carefully with bleeding

72. Myopathy Pharmacologic D/C Medications Prednisone Carnitine supplement Antioxidants: Vit A and E Medrol dose pack to start. If repeat start with methylprednisolone 10mg daily. Watch for CD4 decrease Vitamin A 2000 mcg daily Vitamine E 1,000 units daily Watch for bleeding Carnitine 1gm po qd (333mg tid)Medrol dose pack to start. If repeat start with methylprednisolone 10mg daily. Watch for CD4 decrease Vitamin A 2000 mcg daily Vitamine E 1,000 units daily Watch for bleeding Carnitine 1gm po qd (333mg tid)

73. Nephrolithiasis Treatment Non pharmacologic Plenty of water (>2 liters/day) Pharmacologic Analgesics PRN Urine acidification Analgesic: Medium dose opioid (acetaminophen with codeine) Prevent the use on NSAID due to decrease of renal functionAnalgesic: Medium dose opioid (acetaminophen with codeine) Prevent the use on NSAID due to decrease of renal function

74. Oral/esophageal Ulcers Pharmacologic �Peridex� mouth wash Triamcinolone oral base Intralesional steroid injection Thalidomide Non-pharmacologic D/C offending agent �Amoxan� mouth wash Peridex 10ml bid (can use localy only with a Qtip to prevent teeth satins) Intralessional triamcinolone:lidocaine 1:2 .1ml in each lesion done with 29G insulin syringe. Can repeat in one week Thalidomide 50-400mg po daily for 1 month. Studies support 300mg daily but side effect are significant. Worsening neuropathy �Amoxan� mouth wash Peridex 10ml bid (can use localy only with a Qtip to prevent teeth satins) Intralessional triamcinolone:lidocaine 1:2 .1ml in each lesion done with 29G insulin syringe. Can repeat in one week Thalidomide 50-400mg po daily for 1 month. Studies support 300mg daily but side effect are significant. Worsening neuropathy

75. Pancreatitis Pharmacologic Suspend ddI when clinical signs present IV Fluids High Volume Non Pharmacologic Search for alcohol use Prevent concomitant administration of: valproic acid, thiazide, furosemide, pentamidine, sulfonamides, tetracycline, metronidazole

76. Sleep Disturbance Pharmacologic Early Insomnia � Short acting sedative (lorazepam, zolpidem) Terminal Insomnia � long acting sedative (clonazepam, temazepam) Abnormal dreams � short acting benzodiazepine or low dose antipsychotic medications 1. Sleep Therapy: Zolpidem 10mg hs x 7 days. Repeat in 3 weeks if needed 2. Lorazepam 1mg po hs 3. Clonazepam 1mg po hs 1. Sleep Therapy: Zolpidem 10mg hs x 7 days. Repeat in 3 weeks if needed 2. Lorazepam 1mg po hs 3. Clonazepam 1mg po hs

77. Sleep Disturbance Non Pharmacologic Avoid stimulant food (coffee, chocolate, nicotine) Good sleep hygiene: go to bed at the same time, using bed for sleep and sex only Relaxation technique prior bed time Exercise in a.m. not p.m. Change medications hours