Helping Your Antiretrovirals Help You
Things to Consider When Choosing What Goes in the Tank
Overwhelmed! That is the first word that comes to my mind when I think about an HIV patient who is about to begin antiretroviral therapy for the first time. I think of all the information being sent the way of someone starting therapy -- by physicians, nurses, patient educators, and pharmacists. All of this information is provided in order to help with the start of this important journey, but it can definitely be overwhelming.
As a pharmacist who has worked in an HIV clinic, an outpatient pharmacy, and a medication management mail-order pharmacy, I have seen patients from a variety of perspectives. In each of these different surroundings, some things have remained consistent -- patients have to deal with a myriad of things involved in starting (or switching) antiretroviral therapy, and patients do better if they understand how critical adherence is and come to terms with it. I suggest that anyone thinking about beginning a new medication regimen feel really ready for this big step before taking it.
Rarely is it imperative that antiretroviral treatment be started on an urgent basis. Therefore, you can be open with your physician if you are not yet prepared to begin therapy. Also, before beginning treatment, learn how the medications you'll be taking work in your body and the side effects they may cause. Make sure you are committed to working through complications or problems if they arise.
There are so many different opinions and suggestions about when to start antiretroviral therapy that it is hard to determine the right time for an individual person. Even though things like CD4 counts and viral loads are important factors in making this decision, the most important determinant is that the individual person is ready to start and adhere to therapy.
Adherence to an antiretroviral regimen is extremely important. If a patient starts therapy but does not take it consistently every day, or decides to stop after beginning a regimen, there is a chance of developing medication resistance. However, this does not mean that starting a particular regimen means you can never change it.
If a treatment is not working due to side effects, dosing schedule, or medication intolerability, there is always the option to change to a different combination of medications. It is crucial that the physician be informed and involved with switching therapy. Having an expert help with the change will decrease the potential for building resistance to medications.
Finding a Regimen That Suits You and Your LifestyleAre you ready to start your antiretroviral therapy? If so, there are a few things to keep in mind as you and your physician begin to choose a treatment that is right for you.
Your physician may do some drug resistance testing before you begin ARV therapy to determine if there are any medications to which your virus is already resistant. However, this test is often reserved for patients who are not responding to their current regimen ("treatment-experienced" patients).
With so many things to consider, you may wonder how you or your physician actually decides which combination of drugs to use. The good news is that there are guidelines to help with the decision-making process. It is important to remember, however, that one, guidelines change over time as new medications become available and more information is learned about existing medications, and two, these are just guidelines. Each individual person must find the regimen that will work best ... for that person.
Making it WorkOnce you start your new antiretroviral therapy, you may begin to realize that you are having trouble adhering to your regimen for one reason or another. If that happens, there are a variety of strategies that may help you.
From my experience, patients find pill boxes very helpful for organizing their medications and as a way to remember if they have taken them. Calendars can also be useful because each day can be marked to indicate that a dose was taken. Pill boxes and calendars are both inexpensive tools that can be very helpful. The good news is that adherence has gotten easier as new antiretroviral therapies have been developed that require fewer pills and fewer doses throughout the day.
Sorting Out Drug Side EffectsAntiretroviral therapy has come a long way over the past decade. However, the longer medications are on the market, the more we find out about the side effects they can cause. It is unfortunate, but many of these therapies have a lot of possible short-term and long-term side effects.
It is important to remember that every medication has a list of possible side effects associated with it. That does not mean that everyone taking a particular medication will develop every side effect on the list, or any of them, for that matter. It is a good idea to understand the potential side effects associated with each of your medications, though, so you'll know what to look for if you do experience any problems after starting therapy.
If you have any side effects, or if any side effects you are experiencing become intolerable, make sure to discuss them with your physician. I have seen too many patients who have started therapy, experienced a side effect that they struggled with, then stopped therapy on their own without ever letting the doctor know there was a problem. Patients who stop therapy without speaking with the physician risk developing medication resistance because some medications need to be stopped in a particular order in order to avoid resistance.
Antiretroviral medications can have side effects that are common for the class they are in (e.g., protease inhibitors and gut distress), but there are also side effects that are specific to each medication. It would be impossible to list every side effect for every medication in this article, and probably boring. The point is this: when you start a medication, take time to learn about the side effects from your physician, pharmacist, or written information on that specific medication.
As a class, nucleoside reverse transcriptase inhibitors or NRTIs (drugs like lamivudine, abacavir, and zidovudine) all have the potential to cause some serious side effects. NRTIs can cause pancreatitis, lactic acidosis (a dangerous build-up of acid in the blood), and an enlarged, fatty liver.
The class of protease inhibitors or PIs (drugs like ritonavir, lopinavir/ritonavir, atazanavir, and fosamprenavir) can also cause many side effects. Some of the short-term side effects include diarrhea and nausea or vomiting. Possible long-term side effects include increased cholesterol and triglyceride levels, lipodystrophy (body shape changes), cardiovascular risks, and new or worsening diabetes.
The fusion inhibitor class currently has only one medication in it -- enfuvirtide. The most common side effect is an injection site reaction (ISR) that occurs to some extent in all patients who use it.
It would be easy to think you could expect the side effects common to a class of ARV from any drug in the class, but it's not that simple. Atazanavir, for example, does not share the same lipid-raising profile of its classmates. Likewise, abacavir has the potential for a hypersensitivity reaction (HSR) that the other NRTIs do not, and it appears to be less toxic on the cellular level than some of the others in its class. Similarly, the central nervous system effects (like dizziness, vivid dreaming, and mood changes) associated with efavirenz do not extend to the other drugs in the NNRTI class.
Managing Side EffectsManaging side effects from antiretroviral therapy can sometimes be a difficult task. However, it's important to manage side effects not only because it may make you feel better, but because side effects are a leading cause of treatment non-adherence.
It is possible that a side effect could occur that cannot be managed with additional medications or other supportive measures, which could become intolerable. If that happens, it usually means discontinuing the drug(s) causing the problem and likely making a substitution, with assistance and supervision of your physician.
Some side effects occur with the start of therapy, but will resolve after a couple weeks of continued use. There are other side effects, however, that may need to be managed for the duration of therapy. If that happens, there are steps that you can take to reduce some of the more common ones.
Some side effects may only be found with routine lab work. Depending on the severity, these side effects may be managed under physician supervision with either concurrent drug therapy or a change in antiretroviral therapy. Your physician should be monitoring for things such as:
Please discuss all side effects with your physician before trying to treat them yourself. Sometimes there may be underlying causes of the symptoms that need further evaluation. Also, possible drug interactions between your ARVs and other medications you might be taking need to be considered, even if you're just using a new over-the-counter medication.
Drug InteractionsThe topic of drug interactions is extensive and could comprise an entire magazine issue on its own. Every medication, even ones you think are harmless, may cause drug interactions with your current regimen of antiretrovirals.
Here's a common example that I have seen in the pharmacy. A patient experiences heartburn and comes into the pharmacy to purchase Prilosec OTC, the strongest over-the-counter medication for heartburn. The patient just happens to be on ARV therapy that includes atazanavir. The Prilosec OTC may treat the heartburn, but what the patient does not realize is that a simple item like Prilosec OTC decreases the absorption of the atazanavir. This reduction in atazanavir levels in your blood could lead to the development of resistance to atazanavir.
The above example hopefully illustrates the importance of discussing any new medication with your HIV physician or pharmacist. This includes, by the way, any medication started by a physician other than your HIV physician. Providers who do not practice HIV medicine often have little or no HIV-specific knowledge -- so be sure to discuss any new medications with your HIV provider.
There is a constant flow of new information about ARVs and how they work, which makes it especially important to discuss all new medications with your HIV provider. Hopefully, you feel like you can be honest with your doctor about what you take and your doctor knows what to do with the information.
New Drugs and CombinationsFor the first time in a while, there are several promising medications in the pipeline of the antiretroviral world and a few that are new to the market. Make sure your doctor is aware of and knowledgeable about newly approved drugs and those in development. This is especially important if the existing treatments are not working for you.
Following are some examples of newly approved drugs and drugs that are currently being studied.
In Last Stages of Development
Melissa Ngo, Pharm.D., is an Ambulatory Clinical Pharmacist at the University of Wisconsin-Madison, where she is the lead pharmacist in the Medication Management Mail Order Service. She has worked in the prison clinic of the UW HIV Care Program and currently serves on its community advisory board. She may be reached at firstname.lastname@example.org.
ResourcesAIDS Community Research Initiative of America
In addition to a quarterly treatment newsletter and information on current clinical trials, the AIDS Community Research Initiative of America (ACRIA) offers useful publications on specific topics that can be read on-line or in hard copy. Some examples: Understanding Your Lab Results, Treatment Issues for Women, and Managing Drug Side Effects. Visit www.acria.org.
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