HIV & AIDS Drugs PDF

HIV & AIDS DRUGS Presented By: Groups B5, B6, E17, E18  GROUP MEMBERS B5 B6 ALVAREZ, Juahann Gavin Romeo S. CORPUS, ANDREANNA BENA-FELIZ I CRUZ, Michaela Franchesca L. DARIA, DANICA ALYSSA T...

HIV & AIDS DRUGS Presented By: Groups B5, B6, E17, E18  GROUP MEMBERS B5 B6 ALVAREZ, Juahann Gavin Romeo S. CORPUS, ANDREANNA BENA-FELIZ I CRUZ, Michaela Franchesca L. DARIA, DANICA ALYSSA T FELIA, Charlene R. ESCOTE, JEYLA KRESHIEL F JASMIN, Ethan Simon James N. LESCANO, SHAMILLE EADIE R MALABANA, Conchitina Francesca O. MANGUERRA, ALYSSA C OLORVIDA, Johnrenn Karl C. PALANAS, SOPHIA ISABELLE S POMPOSO, Louise Michaella Q. RECTRA, PATRICIA CLARE F REYES, Cloe Fiona O. REYES, NICOLE JADE T SOLATRE, Weshly Khiana STA ANA, MICHAEL LAWRENCE G TRAGICO, Ramina Nina L. VOTGEN, JESSICA APRIL VANESSA D  GROUP MEMBERS E17 E18 ABAD, Bless L. ACOMPAÑADO, Erika Lei D. BANAAG, Elyssa D.O. CABUNGASON, Mary Jensen Margaret CASTRO, Mary Claire Therese A. L. CHAN, Raphael Dwayne B. CHONG, Juzen Riecia B. CRISOSTOMO, Shrienley Kate G. DE VILLA, Nicole Kate V. FALQUERABAO, Earl Andrew GENIO, Justine Mei G. LAPUZ, Leigh Jan-yle M. PEREZ, John Carvey A. MENOR, Leigh Laurelle Marie RILLAS, John Michael L. QUIERREZ, Reese Ann Margaret C. VALLAR, Sophia C. TIGLAO, Aviel Benedict A. How does HIV and AIDS form in the body? Human Immunodeficiency Virus (HIV) attacks the immune system, specifically targeting CD4 cells, which help the body fight infections. HIV enters the body through contact with infected body fluids, like blood or semen, often through unprotected sex, sharing needles, or from mother to child during childbirth or breastfeeding. HOW DOES IT PROGRESS: Once inside the body, HIV replicates in CD4 cells, weakening the immune system over time. Without treatment, the virus continues to destroy CD4 cells, and when their count falls below 200 cells/mm^2, the infection progresses to Acquired Immunodeficiency Syndrome or AIDS. AIDS is the most severe stage of HIV, where the immune system is so weakened that the person becomes vulnerable to serious infections. Without treatment, people with AIDS usually survive about 3 years, but life expectancy decreases with opportunistic infections.  POSSIBLE SYMPTOMS FOR ACUTE HIV (Primary Infection) Fever, Headache, Muscle aches and joint pain, Rash, SIGNS & Sore throat and painful mouth sores, Swollen lymph glands, Diarrhea, Weight loss, Cough, Night sweats SYMPTOMS SYMPTOMATIC HIV INFECTION Fever, Fatigue, Swollen lymph glands, Diarrhea, Weight loss, Oral yeast infection (thrush), Shingles (herpes zoster), Pneumonia SIGNS & SYMPTOMS WHEN HIV PROGRESSES TO AIDS SYMPTOMS Sweats, Chills, Recurrent fever, Ongoing diarrhea, Swollen lymph glands, Constant white spots or lesions on the tongue or mouth, Constant fatigue, Weakness, Rapid weight loss, Skin rashes or bumps ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) HIV PATHOPHYSIOLOGY HIV Infection (RNA Destruction of CD4+ Immune System Target: CD4+ T cells T cells retrovirus) Weakening CD4+ Count (Indicator Ongoing Replication Immune Response Initial Replication of Immune Function) Acute Retroviral/Primary Early Symptoms Ongoing Replication HIV RNA Test HIV Infection PATHOPHYSIOLOGY INFECTION AND ENTRY HIV primarily targets CD4+ T cells, which are crucial for the immune system. The virus attaches to the CD4 receptor and co- receptors (CCR5 or CXCR4) on the surface of these cells, allowing it to enter and infect them. PATHOPHYSIOLOGY REPLICATION Once inside the cell, HIV uses reverse transcriptase to convert its RNA into DNA. This viral DNA is then integrated into the host cell's genome by the enzyme integrase. The infected cell then produces new viral particles, which bud off and infect other CD4+ T cells. PATHOPHYSIOLOGY IMMUNE SYSTEM DAMAGE Over time, the continuous replication of HIV leads to a significant reduction in the number of CD4+ T cells. This depletion weakens the immune system, making the body more susceptible to opportunistic infections and certain cancers. PATHOPHYSIOLOGY PROGRESSION TO AIDS Without treatment, HIV infection progresses to AIDS, which is characterized by a CD4+ T cell count below 200 cells/mm or the presence of specific opportunistic infections or cancers. At this stage, the immune system is severely compromised. PATHOPHYSIOLOGY CLINICAL MANIFESTATIONS Early stages of HIV infection may present with flu-like symptoms. As the disease progresses, symptoms can include weight loss, chronic diarrhea, fever, and opportunistic infections such as tuberculosis and cryptococcal meningitis. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) HIV LIFE CYCLE Binding and fusion: HIV begins its life cycle when it binds to a CD4 receptor and one of two co-receptors on the surface of a CD4 T-lymphocyte. The virus then fuses with the host cell. After fusion, the virus releases RNA, its genetic material, into the host cell. Reverse transcription: An HIV enzyme called reverse transcriptase (RT) converts the single-stranded HIV RNA to a double-stranded HIV DNA. Integration: The newly formed HIV DNA enters the host cell’s nucleus, where an HIV enzyme called integrase “hides” the HIV DNA within the host cell’s own DNA. The integrated HIV DNA is called a provirus. Transcription: When the host cell receives a signal to become active, the provirus uses a host enzyme called RNA polymerase to create copies of the HIV genomic material, as well as shorter strands of RNA called messenger RNA (MRNA). The mRNA is used as a blueprint to make long chains of HIV proteins. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) HIV LIFE CYCLE Assembly: An HIV enzyme called protease cuts the long chains of HIV proteins into smaller individual proteins. As the smaller HIV proteins come together with copies of HIV’s RNA genetic material, a new virus particle is assembled. Budding: The newly assembled virus pushes out (“buds”) from the host cell. During budding, the new virus steals part of the cell’s outer envelope. This envelope, which acts as a covering, is studded with protein/sugar combinations called HIV glycoproteins. These HIV glycoproteins are necessary for the virus to bind to CD4 and co-receptors. The immature virus breaks free of the infected cell. Maturation: The protease enzyme finishes cutting HIV protein chains into individual proteins that combine to make a new working virus. The new copies of HIV can now move on to infect other cells. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) HIV TRANSMISSION Transmission of the virus occurs primarily by: HIV is spread via: Sexual contact, including oral, vaginal, and anal sex Intimate contact with Direct blood contact, including: Intravenous (IV) drug use with shared needles or shared drug blood, semen, vaginal works fluids, and breast milk Shared contaminated personal care items such as razors Blood transfusions (now extremely rare in the United States) Those at highest risk include: Included in these modes Mother-to-child contact through: Persons who engage in unprotected sex are: Shared maternal-fetal blood Those with multiple sexual partners (either the Accidental needle injury circulation patient or partner[s] of the patient) Artificial insemination Direct blood contact during IV drug users who share needles or drug works with donated semen delivery Infants born to women with HIV Organ transplant Breast milk ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) HIV TRANSMISSION Other factors that increase the risk of MTCT: Mother with a viral load greater than 1000 copies/mL at delivery Risk of mother-to-child Premature rupture of the membranes Hepatitis C virus coinfection transmission (MTCT): Preterm gestation 25% without ART Vaginal delivery Decreases to 1% to 2% HIV is NOT spread by: with successful use of Air or water Mosquitoes or ticks ART Shaking hands, hugging Sharing toilets, sharing dishes or drinking glasses Drinking fountains  HIV/AIDS TESTS 1 2 3 HIV Antibody Tests HIV Antigen/Antibody HIV Nucleic Acid Tests These tests look for Tests NAT detects the actual virus in the blood and can identify HIV earlier than antibodies to HIV in the These tests can detect both HIV antibodies and antigens (specifically antibody tests. blood or oral fluid. It the p24 antigen) produced by the typically takes several virus. NAT is particularly useful in situations where acute HIV infection is weeks for antibodies to suspected and for monitoring viral Advantage: They provide a broader develop after infection. window for detection, allowing for load in patients already diagnosed earlier diagnosis and treatment with HIV. initiation. Types of Tests: Testing Method Testing Method Enzyme-Linked Immunosorbent Assay 4th Generation Tests: These tests can detect This test looks for the presence of HIV RNA (ELISA) HIV infection earlier than antibody tests (the virus's genetic material) and is typically Western Blot Test alone, usually within 2 to 6 weeks after performed on blood samples. exposure. They are performed on blood Window Period samples.  HIV/AIDS TESTS 4 5 5 Rapid Tests CD4 Count Viral Load Tests Rapid tests can provide results in as This test measures the number of CD4 This measures the amount of HIV RNA little as 20 minutes and are often used T-cells (a type of white blood cell) in in the blood. It helps assess how well in community settings, clinics, or at the blood. CD4 cells are crucial for antiretroviral therapy is working and home. immune function, and their count the level of viral replication. helps determine the stage of HIV Confirmation: A reactive (positive) infection. A higher viral load indicates active rapid test must be followed up with infection and increased risk of confirmatory testing, usually an A lower CD4 count indicates a more transmission. antibody or antigen/antibody test. severe immune deficiency. Types of Tests: Rapid Antibody Tests Rapid Antigen/Antibody Tests  Testing Procedures COUNSELING AND SAMPLE COLLECTION LABORATORY PROCESSING FOLLOW-UP Pre-test counseling helps Blood can be drawn via individuals understand the Blood samples may be sent to a venipuncture or through a implications of testing, while laboratory for analysis, while fingerstick for rapid tests. Oral post-test counseling is essential rapid tests can be interpreted fluid tests involve swabbing the to discuss results, regardless of on-site. gums. whether they are negative or positive. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) CLASSIFICATION The two major classification systems: CDC staging system (revised in 2014) HIV disease staging and World Health Organization (WHO) system (revised in 2015) classification systems are important tools for: CDC system: Assesses the severity of HIV disease by CD4+ cell counts and by the Tracking and monitoring the presence of specific HIV-related conditions HIV epidemic Based on the lowest documented CD4+ cell count (nadir CD4+) and Providing the clinician and on previously diagnosed HIV-related conditions patient with information about HIV disease stage and WHO system: Useful in resource-constrained settings without access to CD4+ cell clinical management measurements Classifies HIV disease based on clinical manifestations Can be used by clinicians and those with varying levels of HIV expertise and training in diverse settings ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) INDICATIONS FOR ANTIRETOVIRAL THERAPY (U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES EXPERT PANEL, 2016) The two major classification systems: CDC staging system (revised in 2014) HIV disease staging and World Health Organization (WHO) system (revised in 2015) Due to undiagnosed classification systems HIVare or improper monitoring, only CDC system: 3 in 10 important tools for: Assesses the severity of HIV disease by CD4+ cell counts and by the Tracking and monitoring the 3 in 10 achieve adequate presence of specific HIV-related conditions HIV epidemic Based on the lowest documented CD4+ cell count (nadir CD4+) and viral supression. Providing the clinician and on previously diagnosed HIV-related conditions patient with information ALL HIV-infected about HIV disease individuals stage and regardless of CD4+ count WHO system: Useful in resource-constrained settings without access to CD4+ cell Significantly clinical improved the health measurements management and survival of people with HIV Classifies HIV disease based on clinical manifestations Can be used by clinicians and those with varying levels of HIV To reduce HIV-related morbidity, mortality, and expertise and training in diverse settings transmission. ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) WHAT DOES THE INITIAL TREATMENT INVOLVE? Two NRTIs and a third drug from either the INSTI, NNRTI, or PI classes. Active TB: ART and TB treatments should be started together. ART helps reduce inflammation and related health complications Medication choices depend on: resistance testing comorbidities drug interactions pregnancy status patient readiness.  Prophylaxis of HIV “action taken to prevent disease, especially by specified means or against a specified disease” 1 2 3 Pre-exposure Post-Exposure Preventive Measures Prophylaxis (PrEP) Prophylaxis (PEP) This refers to taking medicine to prevent This refers to taking anti-HIV drugs Using condoms, regular HIV getting HIV very soon after a possible Highly effective for preventing HIV when testing, safe needle exposure to HIV to prevent the taken as prescribed virus from taking hold of our body practices, and ensuring Statistics PrEP reduces risk of getting HIV from This must be started within 72 blood safety prevents the hours (3 days) after possible sex by about 99% transmission of this virus PrEP reduces the risk of getting HIV exposure to the virus or else it from injection drug use by at least 74% won’t work. Despite this, there are a few things to take note of: This should only be used in emergency It is less effective when not taken as situations because it is not meant for prescribed regular use by people who may be Condom use is still important as PrEP exposed to HIV frequently only protects against HIV NUCLEOSIDE/NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS A class of antiretroviral drugs primarily used to treat HIV. NRTIs prevent HIV from making copies of itself and thereby slowing the progression of infection. NRTI These drugs prevent the virus from duplicating, which may slow the spread of HIV in the body. NNRTIs bind to and block reverse transcriptase (an HIV enzyme). HIV uses reverse transcriptase to convert its RNA into DNA (reverse transcription) Interferes with HIV viral RNA-dependent DNA polymerase, resulting in inhibition of viral replication. The first line of drugs is Tenofovir/emtricitabine With Tenofovir, GI complaints and mitochondrial toxicity NRTIs (except abacavir), require dosage requirement in persons with renal insufficiency. NRTI Common Complications Contraindications Most common complications are peripheral neuropathy, myopathy, pancreatitis, and lipoatrophy Liver problems Lactic acidosis, hepatomegaly, steatosis (boxed warning for zidovudine, didanosine, Heart problems stavudine, and emtricitabine) High cholesterol Zidovudine: bone marrow suppression, lipodystrophy, myopathy, hematologic toxicity Didanosine and stavudine: bone marrow suppression, pancreatitis (boxed warning), peripheral Pregnant neuropathy Breastfeeding Lamivudine, tenofovir, and emtricitabine: hepatitis B exacerbations in clients coinfected with HIV and HBV (boxed warning) hormone-based birth Tenofovir: osteomalacia control Emtricitabine: skin hyperpigmentation, immune reconstitution syndrome Abacavir: increased risk of myocardial infarction, immune reconstitution syndrome, severe hypersensitivity reactions (boxed warning), a buildup of lactic acid in the blood (lactic acidosis), liver problems Stavudine: peripheral neuropathy & hepatic transaminases, lactic acidosis, hepatic steatosis  1 Zidovudine (AZT) 2 Didanosine (ddl) 3 Stavudine (d4T) The 7 NRTIs 4 5 Lamivudine (3TC) Abacavir (ABC) 6 Tenofovir (TDF) 7 Emtricitabine (FTC)  Zidovudine (AZT) AZT was the first drug approved to treat HIV. It is a cornerstone in HIV treatment but has been largely replaced by newer drugs due to its side effects. 1 2 3 Dosing How it Works Frequency Side Effects Zidovudine is converted Taken twice daily (300 mg) every 12 into its active form, Common side effects hours Zidovudine triphosphate, Duration: Typically lifelong treatment include nausea, It comes in different forms: oral inside cells headache, and fatigue capsules, tablets, and syrups It interferes with HIV Drug and Food Interactions: Can be These effects can occur due to the reverse transcriptase, taken with or without food, but eating medication’s impact on the gastrointestinal may help if nausea is a problem. system, leading to irritation and changes in blocking the virus from Best to avoid taking it with drugs that motility. Fatigue is also common, as the body copying its RNA into DNA can worsen anemia, like certain cancer adjusts to the medication and its effects on medications. the central nervous system. and slowing down the IV form is also available for hospital infection use Zidovudine (AZT) Adverse Effects Dos and Donts Other Considerations Anemia (low red blood Do: cells) Make sure the patient takes Zidovudine is processed by Muscle weakness the medication as directed. the liver and kidneys, so Low white blood cells. Watch for weakness or patients with liver or kidney unusual tiredness. problems may need a dose These occur because adjustment. Zidovudine targets rapidly Don't: Regular blood tests are dividing cells, including Mix Zidovudine with drugs important to catch early those in the bone marrow that affect bone marrow, like signs of serious side effects. that produce blood cells. some chemotherapy, to avoid serious blood issues. NURSING RESPONSIBILITIES Regularly check for fever, sore throat, and other signs of infection Monitor complete blood count (CBC) due to the risk of anemia and neutropenia Monitor for fatigue, pale skin, dizziness, and shortness of breath, and other symptoms of anemia Monitor liver function regularly Teach patient about adherence Watch for gastrointestinal distress Monitor for lactic acidosis Assess for peripheral neuropathy Educate on drug interactions In educating the patient, nurses must include the purpose of each drug, the dosage schedule, food and fluid restrictions, recommended food choices, and storage of drugs. We must also suggest taking drugs during a daily routine, such as brushing teeth, or using a drug calendar to track drugs taken. RATIONALE Regularly check for fever, sore throat, and other signs of infection: Zidovudine can cause neutropenia, increasing the risk of infections. Early identification helps prevent complications. Monitor complete blood count (CBC): Detects anemia and neutropenia caused by bone marrow suppression, allowing timely intervention. Monitor for fatigue, pale skin, dizziness, and shortness of breath: Early detection of anemia symptoms helps manage complications like reduced oxygen-carrying capacity. Monitor liver function regularly: Zidovudine may cause hepatotoxicity; monitoring ensures prompt action if liver damage occurs. Teach patient about adherence: Consistent use of Zidovudine prevents viral resistance and maintains therapeutic efficacy. RATIONALE Watch for gastrointestinal distress: Common side effects like nausea and vomiting may require management to ensure adherence. Monitor for lactic acidosis: Detects rare but serious side effects such as muscle pain, weakness, or rapid breathing. Assess for peripheral neuropathy: Identifies nerve damage early, helping to prevent worsening pain, numbness, or tingling. Educate on drug interactions: Avoids additive effects with other bone marrow or liver-toxic drugs to reduce risk of severe side effects.  Didanosine (ddl) Didanosine is an older HIV drug, similar to Zidovudine, but made from a substance called inosine (a purine analogue). Like AZT, it blocks the virus from replicating, but in a slightly different way. 1 2 3 Dosing How it Works Frequency Side Effects Didanosine is activated in the Taken once daily and orally. body as Dideoxyadenosine Duration: Lifelong or as long as Common side effects triphosphate. tolerated and effective. include diarrhea, Drug and Food Interactions: This The active form blocks nausea, and rash medication is best taken on an reverse transcriptase, empty stomach, as food can Diarrhea can result from irritation of the stopping the virus from interfere with absorption. gastrointestinal lining and changes in gut making new RNA. It comes in different forms: enteric- motility due to the drug's effects on coated capsules, powder for oral cellular metabolism. Nausea and rash may This prevents the virus from solution, and tablets. occur as part of the body's reaction to the creating new genetic Capsules protect the drug from medication. material. stomach acid to keep it effective. Didanosine (ddl) Adverse Effects Dos and Donts Other Considerations Pancreatitis Do: Didanosine needs dose inflammation of the pancreas Take Didanosine 30 minutes adjustments for kidney occurs due to the drug’s potential toxicity to pancreatic cells, leading to inflammation. before or 2 hours after meals. problems. Peripheral Neuropathy Contraindicated for patients nerve damage causing pain or numbness, Don't: taking ibavirin especially in the hands and feet It’s important to monitor for Didanosine can affect nerve cells, especially Avoid alcohol, as it raises the in the peripheral nervous system, causing signs of: pain or numbness. risk of pancreatitis. Pancreatitis (severe Lactic Acidosis Take with allopurinol (for a dangerous build-up of acid in the blood stomach pain) a critical condition caused by mitochondrial gout) or ribavirin (for Peripheral neuropathy toxicity, which can impair the body’s ability hepatitis C) due to serious (nerve damage) during to clear lactic acid, leading to its accumulation in the bloodstream. risks. treatment. NURSING RESPONSIBILITIES Monitor for pancreatitis Asses for peripheral neuropathy Monitor liver function Monitor Complete Blood Count (CBC) Monitor for lactic acidosis or hepatic steatosis Teach about gastrointestinal side effects Monitor renal function Assess for ophthalmic changes Educate in adherence Teach patient to avoid alcohol RATIONALE Monitor for pancreatitis: Detects early signs of inflammation, such as severe abdominal pain or nausea, as Didanosine can be toxic to the pancreas. Assess for peripheral neuropathy: Identifies nerve damage early, which may require dose adjustments or discontinuation. Monitor liver function: Ensures early detection of hepatotoxicity, especially in patients with pre-existing liver conditions. Monitor Complete Blood Count (CBC): Detects bone marrow suppression, such as anemia or neutropenia, for timely intervention. Monitor for lactic acidosis or hepatic steatosis: Prevents life-threatening complications by recognizing symptoms like fatigue, abdominal pain, or breathing difficulties. Teach about gastrointestinal side effects: Helps patients manage nausea, diarrhea, or vomiting and ensures proper medication timing for better absorption. RATIONALE Monitor renal function: Ensures appropriate drug clearance and prevents toxicity, particularly in patients with kidney impairment. Assess for ophthalmic changes: Detects retinal side effects early; regular eye exams are crucial. Educate in adherence: Maintains effectiveness by preventing viral resistance. Teach patient to avoid alcohol: Reduces the risk of pancreatitis and liver damage, which are exacerbated by alcohol use.  Stavudine (d4T) Stavudine is similar to Zidovudine and is a thymidine analogue, mimicking a natural DNA building block. It is an older drug that is not commonly used anymore due to its side effects. 1 2 3 Dosing How it Works Frequency Side Effects Stavudine is taken twice daily every 12 Stavudine blocks reverse hours Common side effects transcriptase, preventing Duration: Intended for long-term, lifelong include peripheral HIV from copying itself. use but often replaced by other neuropathy and medications if adverse effects develop. Inside the cell, it converts Available as oral capsules and solution for nausea. to its active form adults and children. Once-daily extended-release version is no Peripheral neuropathy occurs because (triphosphate). longer common. Stavudine can damage nerve cells, leading to It gets added to the viral Drug and Food Interactions: Can be taken symptoms such as tingling, pain, or numbness, with or without food. particularly in the extremities. Nausea is often DNA chain, causing chain Alcohol should be avoided, as it can a result of gastrointestinal irritation caused termination, which stops increase the risk of pancreatitis, by the medication. especially in patients with a history of the DNA from fully forming. liver disease. Stavudine (d4T) Adverse Effects Dos and Donts Other Considerations Pancreatitis Do: Stavudine is rarely used can arise from toxic effects on Monitor for signs of nerve pancreatic cells, while lactic today due to its toxicity. damage (pain or numbness in acidosis results from If prescribed, patients mitochondrial impairment. hands or feet) and report Lactic acidosis with kidney impairment immediately. Lipoatrophy (fat loss in face, limbs, may need dose and buttocks) adjustments. is linked to the drug's interference Don't: with lipid metabolism, leading to Combine Stavudine with changes in how the body stores Didanosine to reduce the risk and uses fat. of pancreatitis and lactic Risk increases with long-term use. acidosis. NURSING RESPONSIBILITIES Monitor for: Peripheral neuropathy Pancreatitis Liver function Lactic acidosis or hepatic steatosis Lipodystrophy Assess for muscle weakness (myopathy) Monitor renal function Educate on adherence Avoid concurrent use of neurotoxic drugs Monitor for signs of anemia RATIONALE Monitor for peripheral neuropathy: Early detection of nerve damage helps manage symptoms like numbness or tingling, which may require dose adjustment or discontinuation. Monitor for pancreatitis: Identifies serious inflammation of the pancreas through symptoms or elevated amylase/lipase levels to prevent complications. Monitor liver function: Detects liver toxicity, particularly in at-risk patients, through liver function tests and observation for signs like jaundice or dark urine. Monitor for lactic acidosis or hepatic steatosis: Prevents life-threatening complications by recognizing symptoms such as fatigue, rapid breathing, or abdominal pain. Monitor for lipodystrophy: Identifies fat redistribution changes, allowing for patient education and management of body image concerns. Assess for muscle weakness (myopathy): Detects muscle damage early to address potential mobility issues or severe adverse effects. RATIONALE Monitor renal function: Ensures appropriate drug clearance and adjusts dosing to avoid toxicity in patients with kidney impairment. Educate on adherence: Promotes consistent drug use to prevent viral resistance and ensure the effectiveness of treatment. Avoid concurrent use of neurotoxic drugs: Reduces the risk of worsening neuropathy by avoiding harmful drug combinations. Monitor for signs of anemia: Identifies symptoms like fatigue or pale skin to address rare but possible bone marrow suppression.  Lamivudine (3TC) Lamivudine is a cytosine analogue, mimicking a natural DNA building block. It is widely used in HIV treatment due to its excellent safety and low toxicity. Lamivudine is also effective against hepatitis B, making it useful for patients co-infected with both HIV and hepatitis B. 1 2 3 Dosing How it Works Frequency Side Effects Lamivudine changes to Lamivudine can be taken once daily Common side effects lamivudine triphosphate (300 mg) or twice daily (150 mg). include headache, Duration: Long-term, usually lifelong, in the body. particularly for HIV control. nausea, fatigue, and This form is similar to a Available as tablets, oral solution, and diarrhea. combination pills. DNA building block but Often combined with other drugs for These effects are generally mild and occur as the body adjusts to the medication. different. better viral control. Nausea and diarrhea can stem from Drug and Food Interactions: Taken It stops HIV from orally with or without food. gastrointestinal irritation, while fatigue may be related to the body's response to the multiplying and infecting It’s best to avoid taking it with antiviral effects of the drug. medications that are hard on the new cells. kidneys or liver. Lamivudine (3TC) Adverse Effects Dos and Donts Other Considerations Liver problems can arise due to the drug's Do: Lamivudine is safe and well- metabolism, especially in patients with Ensure the patient follows tolerated, including for existing liver conditions pregnant women. Lactic acidosis (dangerous lactic the prescribed dose. Dose adjustments may be acid build-up) needed for people with kidney occurs when the drug affects Don't: issues, as the drug is excreted mitochondrial function, impairing the body’s ability to metabolize lactate Don’t stop lamivudine through the kidneys. properly, leading to an accumulation suddenly, especially for Avoid concurrent sorbitol- of lactic acid. containing product use when Enlarged liver patients with Hepatitis B, to dosing the oral solution avoid worsening liver formulation Risk increases with long-term use. disease. NURSING RESPONSIBILITIES Monitor liver function Monitor for lactic acidosis Assess for pancreatitis Monitor for signs of hepatitis flare Check for bone marrow suppression Educate on medication adherence Monitor for neuropathy Assess renal function Teach about side effects and monitor the patient Educate on safe practices RATIONALE Monitor liver function: Prevents complications by detecting liver toxicity early through liver function tests and observation for symptoms like jaundice or abdominal pain. Monitor for lactic acidosis: Identifies life-threatening conditions by recognizing signs such as weakness, abdominal pain, or breathing difficulty for prompt intervention. Assess for pancreatitis: Ensures early detection of pancreatitis in high-risk patients, particularly children, by monitoring symptoms and lab results. Monitor for signs of hepatitis flare: Helps manage hepatitis B co-infection by closely observing symptoms and liver function, especially if lamivudine is discontinued. Check for bone marrow suppression: Ensures early identification of anemia or infection risk by regularly monitoring complete blood counts. RATIONALE Educate on medication adherence: Prevents viral resistance and ensures treatment effectiveness by emphasizing consistent and correct medication use. Monitor for neuropathy: Detects rare complications of peripheral nerve damage by assessing for numbness, tingling, or pain in extremities. Assess renal function: Avoids drug accumulation and toxicity by monitoring renal function and adjusting dosages as needed for impaired kidney function. Teach about side effects and monitor the patient: Helps patients manage mild side effects like headache or nausea by providing education and supportive strategies. Educate on safe practices: Promotes public health by teaching patients how to prevent the spread of HIV or hepatitis B through safe sex and avoiding shared personal items.  Abacavir (ABC) Abacavir is a guanosine analogue, resembling the natural guanosine nucleotide. It is a key part of many HIV treatment regimens due to its convenience in once- daily dosing combinations. 1 2 3 Dosing How it Works Frequency Side Effects Abacavir turns into Abacavir can be taken orally once daily (600 mg) or twice daily (300 carbovir triphosphate in mg). Side effects can include the body. Duration: Lifelong for effective HIV nausea, headache, and This active form looks control. Comes as tablets and liquid for fatigue. like a DNA component. children. When HIV tries to use it, Often in combination pills for easier These effects can be due to the body treatment. the process is stopped, adjusting to the medication's presence and Drug and Food Interactions: Abacavir its impact on cellular processes. preventing the virus can be taken with or without food. from reproducing. Patients should avoid alcohol as it may increase liver-related side effects. Abacavir (ABC) Adverse Effects Dos and Donts Other Considerations Do: Liver problems. Abacavir does not require Get the HLA-B*5701 test before Risk of severe hypersensitivity reactions, starting Abacavir. dose adjustments for which can be life-threatening. is related to genetic predisposition; thus, crucial because individuals with this kidney disease, which is an genetic marker are at a higher risk of screening for the HLA-B*5701 allele is essential before starting treatment. developing severe hypersensitivity advantage over other reactions to Abacavir. This genetic marker indicates a higher risk NRTIs. of developing this severe reaction, Monitor for hypersensitivity signs characterized by fever, rash, and (rash, fever, difficulty breathing) in Patients with liver gastrointestinal symptoms. Liver problems can occur due to the drug's effects on liver the first 6 weeks. problems may need a Don't: metabolism. dose adjustment. Don’t give another dose if Doctors perform an HLA-B*5701 genetic hypersensitivity symptoms occur. test to check for this risk before Contact the physician immediately; prescribing. re-challenging can be fatal. NURSING RESPONSIBILITIES Monitor for hypersensitivity reactions Assess HLA-B*5701 status Monitor liver function Educate on medication adherence Monitor for signs of lactic acidosis Provide information about side effects Assess for cardiovascular risk Monitor for signs of Immune Reconstitution Inflammatory Syndrome (IRIS) Educate on safe practices Monitor for potential drug interactions RATIONALE Monitor for hypersensitivity reactions: Hypersensitivity to abacavir can be life- threatening, requiring early recognition of symptoms such as rash, fever, and respiratory issues to prevent severe outcomes. Assess HLA-B*5701 status: Genetic testing minimizes the risk of prescribing abacavir to individuals predisposed to hypersensitivity reactions, ensuring safe medication administration. Monitor liver function: Regular liver function tests detect potential hepatotoxicity early, especially in patients with pre-existing liver conditions, reducing the risk of severe liver complications. Educate on medication adherence: Consistent medication use prevents drug resistance and maintains effective suppression of HIV replication. Monitor for signs of lactic acidosis: Early identification of symptoms such as fatigue, abdominal pain, or labored breathing allows for prompt intervention to manage this rare but serious condition. RATIONALE Provide information about side effects: Educating patients about manageable side effects like nausea or fatigue helps improve adherence and overall treatment experience. Assess for cardiovascular risk: Monitoring cardiovascular health ensures timely detection and management of any increased risk of heart events associated with abacavir use. Monitor for signs of Immune Reconstitution Inflammatory Syndrome (IRIS): IRIS can exacerbate pre-existing infections as immune function improves, so early recognition and management are crucial. Educate on safe practices: Promoting behaviors such as safe sex and not sharing needles prevents further HIV transmission and reinforces public health measures. Monitor for potential drug interactions: Reviewing medications ensures that no harmful interactions occur, maintaining abacavir's efficacy and minimizing side effects.  Tenofovir (TDF) Tenofovir is a nucleotide analogue. It is also highly effective against Hepatitis B, making it a dual-use drug for patients co-infected with both viruses. 1 2 3 Dosing How it Works Frequency Side Effects Tenofovir is taken orally once daily (300 mg) Activated into Tenofovir Duration: Long-term, often lifelong as part of Side effects can include combination therapy. Tenofovir is also diphosphate effective in managing hepatitis B, so nausea, diarrhea, and It mimics a natural DNA consistency is essential to prevent flare-ups in co-infected patients. headaches. building block, blocking Available as tablets Often combined with other antiretrovirals the HIV virus from (e.g., emtricitabine) These effects are often due to There is a dose adjustment for patients with making new DNA moderate to severe renal impairment - dose gastrointestinal irritation and adjustments in the body's metabolic processes as it decreases by increasing dosing interval Drug and Food Interactions: Tenofovir is best acclimates to the medication. taken with food to help with absorption. It should be avoided with drugs that may harm the kidneys. Tenofovir (TDF) Adverse Effects Dos and Donts Other Considerations Kidney problems Do: (nephrotoxicity) Monitor kidney function Tenofovir is a good option Tenofovir can be harmful to kidney for people co-infected cells, potentially leading to regularly impaired kidney function Take calcium and vitamin D with HIV and Hepatitis B. Reduced bone mineral density, supplements However, if medication potentially leading to is stopped suddenly, osteoperosis there is a risk of a Don't: may occur as a result of the medication affecting the Use tenofovir with other severe hepatitis flare. metabolism of calcium and drugs that are known to It is generally safe during phosphate, increasing the risk of harm the kidneys, such as pregnancy. osteoporosis and bone fractures over time NSAIDs (e.g., ibuprofen) Pregnancy category: B NURSING RESPONSIBILITIES Monitor renal function Monitor for bone mineral density loss Assess for lactic acidosis Educate on medication adherence Monitor for gastrointestinal side effects Screen for Hepatitis B Virus (HBV) Reactivation Assess for signs of Immune Reconstitution Inflammatory Syndrome (IRIS) Educate about safe practices Monitor for drug interactions RATIONALE Monitor renal function: Regular kidney monitoring is essential to detect nephrotoxicity, especially in patients with pre-existing kidney conditions. Monitor for bone mineral density loss: Tenofovir can reduce bone mineral density, increasing fracture risk, so regular screening and calcium/Vitamin D supplementation are recommended. Assess for lactic acidosis: Although rare, lactic acidosis can occur, and symptoms like muscle pain or difficulty breathing require immediate attention. Educate on medication adherence: Adherence ensures effective viral suppression and prevents resistance. Discuss strategies for managing missed doses. Monitor for gastrointestinal side effects: Educate on common side effects like nausea and diarrhea, and suggest taking the medication with food to reduce discomfort. RATIONALE Screen for Hepatitis B Virus (HBV) Reactivation: Discontinuation of Tenofovir can trigger HBV flare-ups, so liver function should be monitored in these cases. Assess for signs of Immune Reconstitution Inflammatory Syndrome (IRIS): Monitor patients for IRIS, especially those with advanced HIV, as their immune system recovers. Educate about safe practices: Educate patients on safe sex and harm reduction strategies to prevent HIV transmission, as Tenofovir does not cure HIV. Monitor for drug interactions: Assess for interactions with other nephrotoxic drugs to prevent worsening renal toxicity.  Emtricitabine (FTC) Emtricitabine is also a cytosine analogue. It has an excellent safety profile and is well-tolerated, making it a common choice for first-line HIV therapy. 1 2 3 Dosing How it Works Frequency Side Effects Emtricitabine is converted into Taken once daily (200 mg) Common side effects can into emtricitabine triphosphate often combined with Tenofovir in a include nausea, diarrhea, and This active form mimics one of single tablet to simplify dosing. headaches the DNA building blocks that Duration: Lifelong use is common to HIV uses to replicate maintain viral suppression in HIV. In other cases, it may cause When HIV tries to use it, the Available as oral capsules and hyperpigmentation on the palms combination tablets process is stopped, preventing or soles of the feet Often included in fixed-dose the virus from multiplying. combinations These effects are typically mild and can be Reduce the amount of viral load Drug and Food Interactions: attributed to gastrointestinal irritation and Emtricitabine can be taken with or the body's adjustment to the medication. and increase the number of without food. It’s essential to avoid other CD4 cells that fight off infection medications that could harm the liver or kidneys. Emtricitabine (FTC) Adverse Effects Dos and Donts Other Considerations Liver problems Dosage adjustment is may arise from metabolic Do: required in patients with changes induced by the drug, Administer the medication renal impairment particularly in patients with existing liver disease at the same time every day Stopping the drug suddenly Lactic acidosis can lead to severe can occur due to mitochondrial Don't: exacerbations of HBV in toxicity, leading to the impaired metabolism of lactate and Stop the medication patients co-infected with HIV resulting in its accumulation in suddenly and HBV the bloodstream Cannot be used for It is often combined with children below 3 months other antiretroviral Note: Serious effects are rare. of age medications NURSING RESPONSIBILITIES Monitor for Hepatitis B reactivation Assess renal function Monitor for lactic acidosis Educate on medication adherence Assess for side effects Screen for drug interactions Monitor for Immune Reconstitution Inflammatory Syndrome (IRIS) Educate about safety practices Assess for signs of peripheral neuropathy RATIONALE Monitor for Hepatitis B reactivation: Emtricitabine can trigger HBV flare-ups in co- infected patients, so liver function tests should be monitored to detect any signs of reactivation. Assess renal function: Emtricitabine is excreted through the kidneys, and renal impairment can affect its clearance. Renal function must be regularly assessed, and dosage adjustments made for patients with kidney issues. Monitor for lactic acidosis: Although rare, lactic acidosis can occur. Monitor for symptoms like fatigue, muscle pain, and difficulty breathing, and promptly report any concerns to the healthcare provider. Educate on medication adherence: Ensuring strict adherence to emtricitabine is vital for viral suppression and preventing drug resistance. Discuss strategies to help patients remember their medication schedule. RATIONALE Assess for side effects: Monitor for common side effects such as headache, nausea, and diarrhea. Educate patients on managing these effects, like staying hydrated or taking the medication with food. Screen for drug interactions: Review the patient's medication list to avoid interactions, especially with other antiretroviral drugs or medications affecting liver enzymes. Monitor for Immune Reconstitution Inflammatory Syndrome (IRIS): In advanced HIV cases, patients starting antiretroviral therapy may experience IRIS, with worsening pre-existing infections. Watch for new or worsening symptoms and report them. Educate about safety practices: Emphasize the importance of safe sex practices to prevent HIV transmission, as emtricitabine does not cure HIV. Assess for signs of peripheral neuropathy: Although rare, assess for symptoms of peripheral neuropathy, like tingling or numbness in the extremities, and monitor neurological changes. Patient Adherence Ensuring patient adherence to NRTIs (or any medication regimen) requires a comprehensive approach, addressing understanding, routine, support, and monitoring. Adherence can be improved with once-daily dosing and with fixed-dosage combination products In educating the patient, nurses must include the purpose of each drug, the dosage schedule, food and fluid restrictions, recommended food choices, and storage of drugs. We must also suggest taking drugs during a daily routine, such as brushing teeth, or using a drug calendar to track drugs taken.  Patient Adherence 1. Educate the Patient Thoroughly. EXPLAIN THE DESCRIBE HOW IT WORKS DETAIL POSSIBLE SIDE EFFECTS MEDICATION’S PURPOSE For example, tell patients how their NRTI helps control HIV by Use simple language to explain Clearly outline what side effects to reducing the amount of the the role of each medication in expect (like nausea or diarrhea) and virus in their body. Explain blocking HIV replication and which ones require immediate that consistent use how this keeps the virus under attention (like signs of lactic strengthens the immune control. This helps patients see acidosis). Explain how to manage system, reduces symptoms, the value of sticking to their mild side effects and when to seek and lowers the risk of regimen. help for severe ones. transmission.  Patient Adherence 2. Develop a Medication Routine DAILY SCHEDULES SET UP REMINDERS Encourage using smartphone alarms or Help the patient create a consistent medication reminder apps. Simple tools, schedule by linking their doses to daily such as a pillbox organizer, are also activities (like brushing their teeth or effective, especially for patients who meals) to help form a habit. prefer low-tech solutions.  Patient Adherence 3. Foster Supportive Relationships ESTABLISH A STRONG NURSE-PATIENT ENCOURAGE FAMILY OR FRIEND SUPPORT CONNECTION Let the patient know they can contact you or When appropriate, involve a trusted friend or another healthcare provider with any family member who can remind and encourage questions or concerns. This trust-building the patient to take their medication. reassures them and helps address any doubts they may have about their regimen.  Patient Adherence 4. Make a Follow-Up Plan REGULAR CHECK-INS OFFER POSITIVE REINFORCEMENT Schedule follow-up appointments to monitor Celebrate small milestones, like completing the patient’s health and adherence. During the first week or month. Positive these visits, review any challenges they’re reinforcement can boost the patient’s facing with the regimen and adjust as needed. motivation and sense of achievement.  Patient Adherence 5. Address Barriers Early SIDE EFFECT FINANCIAL AND ACCESS CLARIFY MANAGEMENT SUPPORT MISUNDERSTANDINGD If side effects are preventing Sometimes, adherence is Some patients may miss doses due adherence, work together to impacted by financial or to misunderstandings about their find practical solutions, such accessibility issues. Work with medication. For instance, they as adjusting meal times to case managers or social might think it’s okay to skip doses if reduce nausea or services to connect patients they feel well. Clear up these recommending over-the- with resources like financial misunderstandings to prevent counter remedies for mild assistance, transportation, or inconsistent adherence. symptoms like diarrhea. easier prescription access.  Patient Adherence 6. Monitor and Adjust the Plan as Needed TRACK ADHERENCE STAY FLEXIBLE Regular blood work can measure viral load and If a patient is struggling, work together to provide insight into adherence effectiveness. modify the plan. This could mean simplifying This monitoring helps both the patient and the medication schedule or finding new ways provider see the direct impact of adherence on to manage side effects. health. Other General Information For NRTIs Mechanisms of Diarrhea in NRTIs Note: nausea, diarrhea, abdominal pain This are only transient and improves within the first 2 weeks of therapy 1. Impact on Gut Cell Function NRTIs affect the mitochondria within cells, including those in the gastrointestinal (GI) tract. When these medications disrupt mitochondrial function, it can lead to reduced energy for gut cells, affecting their ability to absorb nutrients and water properly. The gut lining is lined with rapidly dividing cells that require energy to maintain their function. When energy production is impaired, it may lead to a breakdown in the normal structure and function of the gut lining. Mechanisms of Diarrhea in NRTIs 2. Changes in Gut Flora NRTIs can alter the balance of bacteria in the intestines. This dysbiosis (an imbalance in gut bacteria) can contribute to digestive issues, including diarrhea. A healthy gut flora is crucial for nutrient absorption and overall gut health. Mechanisms of Diarrhea in NRTIs 3. Direct Irritation of the GI Tract Some NRTIs can directly irritate the gastrointestinal mucosa, leading to inflammation. This inflammation can cause increased intestinal motility (the speed at which food moves through the digestive system), resulting in diarrhea. Patients may experience cramping or abdominal discomfort alongside loose stools as a result of this irritation. Mechanisms of Diarrhea in NRTIs 4. Altered Absorption of Water and Nutrients When gut cells are not functioning optimally due to mitochondrial impairment, their ability to absorb water and nutrients is compromised. This can lead to increased fluid in the intestines, resulting in loose or watery stools. The impaired absorption can also lead to malnutrition or dehydration if diarrhea is severe or prolonged. Lactic Acidosis What it is A condition characterized by the buildup of lactic acid in the bloodstream, leading to a decrease in blood pH Symptoms: (making it more acidic). Nausea and vomiting Abdominal pain or discomfort This can result in metabolic acidosis, which can be life- Rapid breathing or threatening if not addressed. shortness of breath Muscle weakness or fatigue Mechanism Interferes with mitochondrial function in cells. Mitochondria are essential for energy production and Unexplained weight play a crucial role in metabolizing lactate. loss Confusion or altered mental status in When mitochondrial function is impaired, the body’s severe cases ability to convert lactate into usable energy is compromised, leading to increased levels of lactic acid in the blood. Hyperpigmentation What it is refers to darkening of the skin or mucous membranes. This condition is characterized by the increased Common Sites: production of melanin, the pigment that gives skin its Hyperpigmentation often color. occurs on sun-exposed areas, such as: The face Mechanism Certain NRTIs, especially Zidovudine and Emtricitabine, can cause hyperpigmentation as a result of direct effects Palms of the hands Soles of the feet on melanocytes (the cells responsible for melanin Nails (may show a production). dark streak) The exact mechanism isn’t fully understood, but it may involve the drug-induced irritation of the skin or changes in the skin’s structural integrity, leading to increased melanin deposition in the affected areas. NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS Type of antiretroviral medication, are commonly used in HIV treatment. These drugs are also called as “non-nukes” and are often prescribed in combination with others, inhibit HIV reverse transcriptase to prevent the virus from replicating by blocking its conversion of RNA into DNA. NNRTI Compared to NNRTI, this does not require intracellular metabolism They directly bind to reverse transcriptase (RT) enzymes and block DNA polymerization Has a lower pill burden compared with most PI- based regimen Major disadvantage are the prevalence of NNRTI- resistant viral strains Required for treatment-naive patients before starting therapy CYP3A4-mediated drug interactions are common, affecting many drugs, and rilpivirine's bioavailability is reduced by proton pump inhibitors (PPIs).  1 Efavirenz (EFV) 2 Etravirine (ETR) The 5 NNRTIs 3 4 Delavirdine (DLV) Nevirapine (NVP) 5 Rilpivirine (RPL)  Efavirenz (EFV) Efavirenz inhibits the activity of reverse transcriptase, an enzyme critical for the replication of HIV. 1 2 3 Dosing How it Works Frequency 3 Side Effects The first-choice drug within the NNRTI class and 600 mg h.s (at bedtime) or Common side effects include is the only one that before on an empty rash, nausea, diarrhea, penetrates the stomach dizziness, insomnia, abnormal cerebrospinal fluid (CSF). Duration: Typically lifelong dreams, impaired Efavirenz inhibits the as HIV has no cure. concentration, and anxiety. activity of viral RNA- However, other directed DNA polymerase, alternative medications The medication affects the skin, GI tract, and CNS. or reverse transcriptase. may be considered if As such, enzyme activity side effects are and viral replication is intolerable and virus reduced. becomes resistant. Efavirenz (EFV) Adverse Effects Dos and Donts Other Considerations Women should avoid Efavirenz due to Allergic reaction Do: potential teratogenic effects. Convulsion Take on an empty Undergo pregnancy testing before starting therapy. Liver failure neuropathy stomach Females must use effective Suicide contraception during treatment and for Abnormal vision Don't: 21 weeks after discontinuation due to the drug's long half-life. Drink excessive or chronic Take caution with patients with a history EFV can cause severe alcohol as alcohol may of mental illness or drug abuse, liver adverse effects due to its contribute to increased impairment, and seizure disorder. can cause neuropsychiatric symptoms extreme effects to the liver adverse effects when such as dizziness, sedation, nightmares, and CNS. taken with this drug euphoria, or loss of concentration. RATIONALE Side Effects EFV causes side effects as it inhibits the reverse transcriptase enzyme in HIV. The skin and GI side effects result from its interaction with immune and digestive system pathways, triggering inflammatory or irritation responses. Lastly, since EFV can cross the blood brain barrier, this affects neurotransmitter function, brain activity, and mood regulation which explain the CNS symptoms. Adverse Effects EFV can provoke immune responses which may cause allergic reactions, liver failure, impact liver enzymes leading to hepatotoxicity, and affect nerve cells. For its effect to CNS, its ability to cross the blood-brain barrier, and may disrupt the neurotransmitter balance, this may lead convulsions, suicidal thoughts, and abnormal vision. RATIONALE Efavirenz should not be combined with midazolam, rifabutin, triazolam, or ergot derivatives. For midazolam and triazolam, it induces the cytochrome P450 enzyme system which leads to reduced plasma levels of these benzodiazepines. This leads to inadequate sedation, reduced therapeutic effect, and depending on the metabolism of the patient, the CNS is at risk for toxicity or prolonged sedation. For rifabutin, the drug is metabolized by CYP3A4 which can decrease its plasma concentrations. As such, it can lower the effectiveness of this drug and be ineffective in the TB treatment of HIV patients. For ergot derivatives, it may lead to increased levels which puts the patient at risk for severe ergot toxicity; symptoms include vasospasm, ischemia, and gangrene. NURSING RESPONSIBILITIES Emphasize the importance of taking efavirenz as directed Inform the patient that efavirenz does not cure HIV or AIDS or prevent associated or opportunistic infections. Instruct patient to report signs of kidney stones (renal calculi), including bloody urine, severe pain in the side and back, pain on urination, and a persistent urge to urinate. Advise the patient about the likelihood of GI reactions, including nausea, vomiting, diarrhea, abdominal pain, heartburn, and loss of appetite. Instruct patient to report other troublesome side effects such as prolonged or severe headache, sleep loss, abnormal dreams, or a decreased sense of touch (hypoesthesia). RATIONALE Emphasize the importance of taking efavirenz as directed Ensures consistent drug levels to maximize effectiveness and prevent resistance. Inform the patient that efavirenz does not cure HIV or AIDS or prevent associated or opportunistic infections. Helps set realistic expectations and encourages adherence to the full treatment plan. Instruct patient to report signs of kidney stones Early reporting of symptoms like bloody urine or severe pain allows prompt management of potential renal issues. Advise the patient about the likelihood of GI reactions Prepares the patient for common side effects, promoting awareness and timely management to maintain adherence. Instruct patient to report other troublesome side effects Monitoring severe or prolonged symptoms like headaches or abnormal dreams ensures early intervention and improves comfort during therapy.  Etravirine (ETR) Etravirine is a second-generation NNRTI that works by binding to and inhibiting the reverse transcriptase enzyme of HIV. 1 2 3 Dosing How it Works Frequency 3 Side Effects Binds to viral reverse transcriptase to block Usual dosage is 200 mg taken Common side effects replication. twice daily after meals to Directly inhibits HIV type 1 ensure optimal absorption. include rash, nausea, reverse transcriptase. Duration: Lifelong as long as and increased levels of Prevents movement of it controls the viral load, LDL cholesterol. enzyme subdomains needed supports immune function, for viral replication. tolerates the medication ETR causes these side effects without significant side Adapts to mutated enzyme as a result of interacting with effects, and no resistance binding sites efficiently. the body’s immune system and from the virus. If resistance Maintains important metabolic system. and side effects manifest, interactions to continue other alternative NNRTIs will inhibiting the virus. be considered. Etravirine (ETR) Adverse Effects Dos and Donts Other Considerations GI disorders Fatigue Do: Watch out for Peripheral neuropathy Take with a meal and add hypersensitivity, risk of Increased creatinine more fluids severe skin reactions, Diarrhea and risk of immune Stevens-Johnson syndrome Erythema multiforme angina Don't: reconstitution Angioedema Take drugs such as syndrome. Toxic epidermal necrolysis artemether, carbamazepine, and ETR causes adverse effects to the GI cariprazine tract, immune system, and CNS effects. RATIONALE Side Effects Rash and nausea are common immune and GI reactions that are caused by the medication causing an allergic or hypersensitivity reaction and irritating the stomach lining respectively. Contrarily, the increased LDL levels may result from the medication affecting lipid metabolism which affects the body’s processing of fat. Adverse Effects GI disorders, fatigue, and diarrhea manifest as a result of the medication’s impact on the digestive system and metabolism. For peripheral neuropathy, nerve toxicity can occur as it may interfere with the normal function of nerve cells while inhibiting reverse transcriptase. Lastly, severe reactions that affect the immune system include stevens-johnson syndrome, erythema multiforme, toxic epidermal necrolysis, and angioedema are serious immune-mediated responses or hypersensitivity reactions that may occur from triggering inflammatory skin and systemic responses. NURSING RESPONSIBILITIES Make sure patient takes the medication after meal for better absorption. Monitor for skin effects, especially severe skin reactions such as Steven-Johns syndrome or epidermal necrolysis. Moreover, monitor signs of liver problems, allergic reactions, or reconstitution syndrome. Nursing interventions for stevens-johnson syndrome include the ff: Administer analgesics as prescribed to manage pain Clean the wound, change the dressing, prevent infection, and promote healing by encouraging vitamin C intake Monitor for dehydration and electrolyte imbalance as SJS can lead to fluid loss from the skin detaching NURSING RESPONSIBILITIES Educate the patient on the importance of taking the medication on time as not taking it on time will make it harder to cure the condition. Do not give this medication when the patient has taken anticonvulsants or other antiretrovirals as it may lead to reduced effectiveness or increase the toxicity. Establish baseline vital signs and liver function tests to note for any changes after taking the drug as this drug affects the G.I tract. RATIONALE Administer after meals. Ensures better absorption and drug effectiveness. Monitor for severe skin reactions (e.g., SJS, TEN), liver issues, allergies, and IRIS. Detects life-threatening complications early. Provide SJS care (analgesics, wound care, infection prevention, monitor fluids/electrolytes). Manages symptoms, promotes healing, and prevents complications. Educate on timely medication adherence. Maintains drug effectiveness and prevents resistance. Avoid co-administration with anticonvulsants or other antiretrovirals. Prevents reduced efficacy or toxicity. Establish baseline vitals and liver tests. Monitors for changes due to GI and systemic effects.  Delavirdine (DLV) Delavirdine inhibits reverse transcriptase by binding to its active site. It is used as part of an antiretroviral therapy regimen to manage HIV infection, but is less commonly prescribed due to interactions with other medications. 1 2 3 Dosing How it Works Frequency 3 Side Effects Delavirdine inhibits 400 mg three times a Common side effects HIV replication by day include rash, increased 100 mg may be directly binding to transaminase levels, mixed with 3 oz reverse water; 200 mg tabs headaches, nausea, transcriptase, taken as intact tablet diarrhea reducing the risk of Duration: Taken for life as long as it maintains DLV causes these side developing AIDS and viral suppression, effects as it affects our skin, HIV-related tolerable side effects, immune system, and GI complications. and no resistance by the system. virus Delavirdine (DLV) Adverse Effects Dos and Donts Other Considerations Rash (including Stevens-Johnson Do: Take note if patient is allergic to For patients with syndrome) along with other symptoms such as: DLV achlorhydria, they should Can be taken with or without take this drug with a glass of Hepatotoxicity, with risks of elevated liver transaminases food. orange or cranberry juice. Hepatic failure Orange juice helps with the Fever Don't: absorption of the medicine. Hives Take with antacid medications Delavirdine and Nevirapine Itching Swelling of face within 1 hour as it may prevent (NVP) can be taken without Hoarseness Delavirdine absorption. regard to food, while other Difficulty breathing or swallowing Administer with astemizole, NNRTIs should be taken with These are the adverse effects of this medication carbamazepine, cisapride, and food to enhance absorption. because it affects our skin and immune system. conivaptan. RATIONALE Side Effects Rash occurs as a result of immune response or hypersensitivity reaction. Increased transaminase levels occur due to the liver experiencing an inflammatory reaction which leads to higher transaminase levels. Headaches, nausea, and diarrhea are common effects which happened as a result of its effects to metabolism, digestive (cause irritation), and nervous system (affect neurotransmitter systems). Adverse Effects Rash, fever, hives, itching, face swelling, hoarseness, and difficulty breathing occur as a result of hypersensitivity or allergic reactions to the medication. This happens as the immune system mistakenly identifies the drug as harmful which leads to an inflammatory response. Angioedema and anaphylaxis may possibly occur as a result of the drug being recognized as a harmful substance, causing the release of histamines. As such, deeper tissues swell (angioedema) and cause severe allergic reactions (anaphylaxis) and can lead to difficulty breathing and swallowing.  Why do we avoid administering DLV with: ASTEMIZOLE CARBAMAZEPINE CISAPRIDE CONIVAPTAN DLV inhibits the DLV can increase Carbamazepine metabolism of cisapride levels, induces liver enzymes Both drugs may affect astemizole which leading to higher risk of which lower liver metabolism and increased its drug level life-threatening effectiveness of DLV may cause adverse and increased risk of arrhythmias due to through reducing effects in the GI tract. severe heart cisapride’s effects on plasma concentration. arrhythmias. the heart. NURSING RESPONSIBILITIES Monitor side effects such as headache, nausea, rash, and depression. Report any severe rashes and hypersensitivity reactions. Instruct patients to take the medication on time for a more effective treatment. Check if the patient has liver impairment before giving this medication as it may lead to hepatotoxicity. RATIONALE Monitor side effects such as headache, nausea, rash, and depression. Report any severe rashes and hypersensitivity reactions. Early detection and reporting prevent complications, including severe allergic reactions like Stevens-Johnson syndrome. Instruct patients to take the medication on time for a more effective treatment. Ensures consistent drug levels, improving efficacy and reducing the risk of resistance. Check if the patient has liver impairment before giving this medication as it may lead to hepatotoxicity. Prevents worsening liver function and avoids potential toxic effects.  Nevirapine (NVP) Nevirapine decreases HIV replication by binding to reverse transcriptase, preventing the enzyme from functioning properly. 1 2 3 How it Works Dosing Lowers HIV levels in the Frequency 3 Side Effects blood by inhibiting viral For the first 14 days, 200 Common side effects replication, which helps mg is taken once daily, slow the destruction of include rash, including followed by 200 mg twice the immune system when daily thereafter. Stevens-Johnson used in combination with Duration: For HIV, it is syndrome, as well as other antiretroviral typically taken daily as part symptomatic hepatitis. medications. of a lifelong treatment All NNRTIs except NVP are regimen. Also, it depends The medication affects metabolized by the liver on the condition being the skin and liver. and excreted in feces, treated and the individual’s response to while NVP is primarily the medication. excreted in urine. Nevirapine (NVP) Adverse Effects Dos and Donts Other Considerations Ulcerative stomatitis Do: Discontinue if hepatitis signs or The drug is classified as Increased liver function tests (LFTs) increased transaminase levels with rash pregnancy category B, Abdominal pain occur. indicating no risk in animal Paresthesia Stop if severe skin or hypersensitivity Nausea studies, but caution should reactions happen. Anemia Take the medication without regard to still be exercised as human Peripheral neuropathy meals. data are insufficient. Myalgia Delavirdine and nevirapine Don't: (NVP) can be taken without The adverse effects result from its Give to patients with liver impairment Avoid crushing or chewing extended- regard to food, while other impact on the mucosal lining, liver release tablets. NNRTIs should be taken with function, bone marrow, and nerve and Administer to females with CD4+ counts food to enhance absorption. muscle tissues. over 250/mm³. RATIONALE Side Effects NVP can cause these side effects due to its immune-modulating effects, which can trigger hypersensitivity in some individuals. The drug can also lead to symptomatic hepatitis, as it may cause liver inflammation by affecting liver enzyme activity. These arise from the body’s immune response to NVP, resulting in skin and liver complications. Adverse Effects NVP causes these adverse effects because of its effects on the mucosal lining and digestive system. It may also increase l