Nurses with question
Feb 4, 2006
41 y/o with HIV for 2 years says he is ready to take HIV meds. Past med history is large cell lyphoma 2 yrs ago treated with 4 cycles of CHOP with excellent rresponse, seroconcerted to PPD 6 years ago, treated with 1 year of INH. Today exam is WNL. Lab are WBC 3.3, Lymphs 40.5, Mono 13.0, Eos 8.8, Neutros 36.8, CD4 16%/240cells/mm3 CD 8 is 49, HIV RNA is 60,100. Is antiretroviral therapy indicated? Is prophylactic therapy for any HIV-associated opportunistic pathogen indicated? What options are avaiable ? What regime is indicated for dysphagia? What parameters should be selected to monitor the clinical efficacy and toxicity of the pharmacotherapeutic regime? What frequency should be used? What info is given to this man for education?
Response from Dr. Young
Thanks for your post.
If I was caring for your patient (with a prior history of malignancy and with his CD4 counts), I would certainly recommend starting antiretroviral therapy. With his current CD4 count >200, there's no immediate indication for primary prophylaxis for opportunistic infectioin, but the time is close.
As for regimens for dysphagia, there's no absolute guideance-- there are some medications available as exilirs; others with dysphagia prefer capsules to tablet formulation of medications. It would be worth understanding the basis of the dysphagia- is it because of esophageal infection or residual tumor?
I typically monitor patients at baseline (CD4 count, viral load, diagnostic panel, resistance tests) and then most closely for the first weeks of treatment-- at 2 weeks, a check for side effects, dosing requirements and toxicity. At week 4, the first labs to verify viral load reduction and CD4 (the later is somewhat optional). I look for at least a one log (90%) reduction in viral load at this point. Labs and clinic visits are usually done every three-four months.
As for education-- this is a big topic-- the natural history of HIV disease, goals of treatment, risks and benefits of therapy; adherence, safe sex, safe drugs, doctor-patient relationship and communication skills; just to start. This takes investment of effort and time; for patients with web access, of course, this website is also of a lot of value.
I hope this helps, BY
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