Transcript Guidelines for the use of antiretroviral agents in HIV

Guidelines for the use of
antiretroviral agents in HIV
infections in Taiwan,
revised in 2002
by Infectious Diseases Society
of the ROC and Taiwan AIDS
Society
Guidelines for the use of antiretroviral
agents in HIV infections
Significant progress in the field of antiretroviral
therapy over the past year .
New drugs approved for clinical use and new
insights gained in many aspect of therapy.
An update of the first “Guidelines for the use of
antiretroviral agents in HIV infections in Taiwan”
established in March 11, 2001, and organized a
meeting on November 24, 2001.
Guidelines for the use of antiretroviral
agents in HIV infections
The new guidelines: more conservative in the
initiation of treatment in asymptomatic patients, and
offered an option for treatment in patients with
CD4+ T cells >350/mm3
Guidelines for the use of antiretroviral
agents in HIV infections
Other important issues not included in this guidelines:
the side effects, drug resistance, patients compliance,
prevention of opportunistic infections,
Immunotherapy, and vaccine.
Guidelines for the use of
antiretroviral agents in HIVinfected patients
A. General consideration
1.When to start
(1) Acute HIV infection: treatment should be offered.
(2) Symptomatic: treatment should be offered.
(3) Asymptomatic:
Adult:
Treatment should be offered:
CD4+ T cells <350/mm3, or
HIV RNA >30,000 copies/ml (bDNA), or
HIV RNA >55,000copies/ml (RT-PCR).
Treatment may be deferred:
CD4+ T cells >350/mm3, or
HIV RNA <30,000 copies/ml (bDNA), or
HIV RNA <55,000copies/ml (RT-PCR).
Pediatrics:
Treatment should be offered to all newly
diagnosed infected children, if universal early
treatment not feasible, treatment should be
offered if there is evidence of immune
suppression as followings:
CD4+ T cells
Ages
No./mm3
%
1-5 yrs
<1000
<25%
6-12 yrs
<500
<25%
2.When to change
(1)Virologic failure:
a. A reduction in plasma HIV RNA of less than
0.5 to 0.7 log10 4 weeks following initiation of
therapy; or less than 1 log10 by week 8.
b. Failure to suppress plasma HIV RNA to
undetectable levels within 4 -6 months after
initiation of therapy.
c. Repeated detection of virus in plasma after initial
suppression to undetectable level, suggesting the
development of resistance.
d. Any reproducible significant increase, defined as
3-fold or greater, from the nadir of plasma HIV
RNA not attributable to intercurrent infection,
vaccination, or test methodology.
(2) Toxicity
(3) Intolerance
B. Recommended regimensa
1.Acute HIV infection
Drug of choice
A
B
Indinavir
Combivirb
Saquinavir
d4T+3TC
Ritonavir
ddI+3TC
Nelfinavir
Efavirenz
Nevirapine
Saquinavir+Ritonavir
Indinavir+Ritonavir
Kaletrac



Alternative
A
Abacavir
B
AZT+3TC
AZT+ddI
AZT+ddc
d4T+ddI
2.Asymptomatic HIV infection
Drug of choice
A
B
Indinavir
Combivirb
Saquinavir
d4T+3TC
Ritonavir
ddI+3TC
Nelfinavir
Efavirenz
Nevirapine
Saquinavir+Ritonavir
Indinavir+Ritonavir
Kaletrac
Alternative
A
B
Abacavir
AZT+3TC
AZT+ddI
AZT+ddc
d4T+ddI
3.Advanced HIV infection
Drug of choice
A
B
Indinavir
Combivirb
Saquinavir
d4T+3TC
Ritonavir
ddI+3TC
Nelfinavir
Efavirenz
Nevirapine
Saquinavir+Ritonavir
Indinavir+Ritonavir
Kaletrac
Alternative
A
B
Abacavir
Nevirapine
AZT+3TC
AZT+ddI
AZT+ddc
d4T+ddI
4.HIV-infected pediatric patientsd
Drug of choice
A
B
Ritonavire
Nelfinavirf
AZTg+3TCe
AZTg+ddIf
Alternative
A
B
Abacavire
Nevirapinef
AZTg+ddCe
d4Te+3TCe
d4Te+ddIf
5.HIV infection in pregnant women
Drug of choice
A
B
Nevirapine
Saquinavir
Combivir
AZT+ddI
Ritonavir
Alternative
A
B
Nelfinavir
Indinavir
AZT+3TC
d4T+3TC
6.Prophylaxis after occupational exposureh
Drug of choice
A
B
Indinavir
Combivir
Alternative
A
B
Nelfinavir
Saquinavir
AZT+3TC
d4T+3TC
Abbreviations:
d4T : Stavudine
3TC: Lamivudine
AZT: Zidovudine
ddI: didanosine
ddC: Zalcitabine
aAntiretroviral drug regimens are comprised of
one choice from column A and B.
bCombivir: AZT+3TC.
cKaletra: lopinavir/ritonavir.
dAll
regimens used for adults are also
recommended for pediatrics.
eOral solution formulation available.
fPowder formulation for suspension available.
gSyrup formulation available.
hThe previous treatment regimens of source
patient should be taken into consideration; the
duration of treatment is 4 weeks; the risk
group should be considered, if contact with
body fluid except blood, dual therapy is
recommended.
Guidelines for the Use of Antiretroviral Agents in
HIV-1 infected in Adults and Adolescents
October 29, 2004
Developed by the Panel on Clinical Practices for
Treatment of HIV infection convened by the
Department of Health and Human Services
(DHHS)
It is emphasized that concepts relevant to HIV
management evolve rapidly. The panel has a
mechanism to update recommendations on a
regular basis, and the most recent information is
available on the AIDSinfo Web site.
(http:/AIDSinfo.nih.gov).
When to treat:
Indication for antiretroviral therapy
Panel’s Recommendations
Antiretroviral therapy is recommended for all
patients with history of an AIDS-defining
illness or severe symptoms of HIV infection
regardless of CD4+ T cells count.
Antiretroviral therapy is also recommended for
asymptomatic patients with CD4+ T cells
< 200/mm3.
Asymptomatic patients with CD4+ T cells
counts of 201- 350/mm3 should be offered
treatment.
Asymptomatic patients with CD4+ T cells
counts of >350/mm3 and plasma HIV
RNA>100,000 copies/ml, most experienced
clinicians defer therapy but some clinician
consider initiating treatment.
Therapy should be deferred for patients with
CD4+ T cells counts of >350/mm3 and plasma
HIV RNA<100,000 copies/ml.