Transcript Chapter 36 Drugs for Viral Infections HIV-AIDS

HIV & AIDS
Hepatitis
Herpes Virus
Influenza
Chapter 36
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Demographics
 World-wide in 2006: 65 Million people living with
HIV/AIDS
 U.S.: 1.1 Million cases to date:
 40,000 new cases each year
 2nd leading cause of death among 25-44 y.o.’s
 1/5 unaware of being infected
 African Am. 7 X more likely to be infected.
• CDC 2009
• Pharmacology for Nurses 3rd Ed. 2011
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Landscape
 World-wide demand to continue the development of
new antiviral drugs
 HIV Transmission: exposed to contaminated body
fluids (blood, vaginal/ seminal), sharps & needle
punctures, splash to broken skin/mucus membrane.
Newborns can be infected during pregnancy, birthing
or from brest milk.
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HIV Disease Landscape
 Causes a gradual destruction of host immune system,
uniformly fatal when untreated, demands continuous
supply of medications for survival.
 Rapid rebound of virus if meds are stopped
 Rapid mutation requires novel approaches of
treatment

Pharmacology for Nurses 3rd Ed. 2011
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Pharmacotherapy:
Highly Active AntiRetroviral Therapy
(HAART)
 Goal: Lower Viral Load (HIV RNA assay) to
undetectable levels or below 50 copies/ml
 Goal: Maintain CD4 counts >500 cells/ml
 Goal: Begin HAART if CD4 Count <200 cells/ml
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HAART Continued
 Goal: Maintain or increase Quality of Life
 Goal: Decrease Transmission from Mother to
Fetus/New Born
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HAART Profile
 Each Drug Class disrupts a specific phase of the HIV
cell replication cycle
 Multiple Drug Regimen to reduce drug resistance
 HAART Drugs are specific to HIV
 Treatment is for remainder of the clients’ life
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HAART Profile Continued
 Rapid mutation of HIV can make HAART ineffective.
 HAART can damage the host cell while seeking to kill
the intracellular virus or parasite.
 70% decline in death rate in U.S.
since HAART was instituted.
Pharmacology for Nurses 3rd Ed. 2011
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Case Study
 Mr. S. is a 56 y.o. male recently
admitted to the Medical/Surgical Unit
for Left Total Knee Replacement (Lt
TKR). He has a history of Coronary
Artery Disease, Peptic Ulcer Disease,
and smoking. He is HIV+.
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Case Study Cont’ed
 He had his surgery yesterday (2nd day
post op) and is resuming his HIV
medications: Zidovudine, Tenofovir &
Kaletra. Today’s lab results: WBC’s 4.5,
Hemoglobin 11, Hematocrit 30,
Platelets 45,000, Na+ 135, K+ 4.5.
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Drug Classifications:
1) Nucleoside & Nucleotide
Reverse Transcriptase Inhibitors
(NRTI/NtRTI)
1) Zidovudine (Retrovir, AZT) (NRTI prototype drug)
 100mg PO Q4H on empty stomach
 Used in combination with other HAART Medications
to be effective due to widespread resistance
2) Tenofovir (Viread) 300 mg PO daily
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Adverse Effects
 Common: Fatigue, generalized weakness, myalgia,
n/v/, headache, abdominal pain, anorexia, rash.
 Serious: bone marrow suppression, neutropenia,
anemia, granulocytopenia, lactic acidosis, steatorrhea,
neurotoxicity.
 Contraindications: Hypersensitivity. Use cautiously
in patients with pre-existing anemia or neutropenia
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NRTI’s: How do they work?
 NRTI’s resemble human nucleosides, the building
blocks of DNA. The HIV virus incorporates the
medications, which are nonfunctioning units, into its
DNA chain, stopping HIV synthesis. This action
prevents the HIV virus from inserting itself into the
human chromosome.
 Note: High degree of Cross-Resistance among NRTI’s
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NtRTI’s: How do they work?
 NtRTI’s method of action disrupts the
transcriptase enzyme of the HIV virus,
thus stopping viral replication.
• Nursing 2008 Drug Handbook
• Pharmacology for Nurses 3rd Ed. 2011
• Davis Drug Guide 2011
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Lopinavir/ritonavir (Kaletra)
Protease Inhibitor (Prototype drug):
400mg/100mg PO BID with food or after meals
(ritonavir prevents hepatic breakdown of lopinavir,
increasing it’s blood level and half-life).
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Protease Inhibitors (PI’s)
 Block the viral enzyme Protease, which is responsible
for the final assembly or cleavage of the HIV
polyprotein, keeping the HIV virion noninfectious.
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Lopinavir/ritonavir (Kaletra)
 Common Adverse Effects: Nausea, vomiting,
diarrhea, abdominal pain, headache, dyspepsia.
Serious Adverse Effects: Anemia, leukopenia,
Deep Vein Thrombosis, pancreatitis,
lymphadenopathy, hemorrhagic colitis,
hyperglycemia, lipodystrophy.
Cautious Use: Hepatic Impairment, Diabetes.


Pharmacology for Nurses 3rd Ed. 2011
Prentice Hall Nurse’s Drug Guide 2009
17
Tulane University
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Mr. S.
 Prior to providing routine 9 AM oral medications
and breakfast, the nurse administers Odansetron
(Zofran), 4mg IV to help prevent nausea and
vomiting, a common side effect of HAART. The
nurse begins evaluating the level of understanding
Mr. S. and his significant other has regarding goals
and expected outcomes, potential and actual
nursing diagnosis, and their implementations
(interventions and rationales).
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Mr. S.
 Mr. S. states he would like to spend some
quiet time with his partner at this time and
asks the nurse if it would be alright to talk
about his disease and drug therapy later
today. The nurse reply's certainly that it is
quite alright and she will come back this
afternoon to talk. Mr. S. tolerated his
medications and his breakfast well.
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Quality and Safety Education for
Nurses (QSEN)
 QSEN Competency: Patient-centered Care.
Recognize the patient or designee as the
source of control and full partner in
providing compassionate and coordinated
care based on respect for the patients
preferences, values, and needs.
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QSEN Continued
 Knowledge: Integrate understanding of multiple
dimensions of patient-centered care: education,
physical and emotional support, involvement of family
and friends.
 Skills: Elicit pt. values, preferences and needs when
implementing and evaluating outcomes of care.
 Attitudes: Respect and encourage pt.’s / significant
other’s expression of needs, preferences, values.

Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. 2007.
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Actual/Potential Nursing Diagnosis:
 Infection
 Risk for Falls / Risk of Injury
 Activity Intolerance / Fatigue
 Pain / Anxiety / Insomnia
 Imbalanced Nutrition, Less than Body Requirements
 Deficient Fluid Volume / Diarrhea
 Ineffective Therapeutic Regimen Management
 Deficient Knowledge
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rd
3
Day Post Op for Mr. S.
 Mr. S. has been tolerating his medication
and diet well. However, the nurse received a
call from the laboratory technician stating
his am lab results are: Hemoglobin is 8,
Hematocrit is 26. His WBC’s are 2 and his
Platelets are 20,000. (All these values are
below his baseline).
 What do we do now?
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st
1 :
 Verify the lab results (critical values are-by
policy-called to the nursing station by the
reporting lab).
 Nurse notifies the Surgeon
 As the nurse, what orders would you expect
to receive?
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Next
 The Nurse would anticipate:
 1) possible transfusion with 1-2 units of Packed Red
Blood Cells (PRBC’s)
 2)possible change/addition in HAART medications
 3) institute protective isolation and observe for
signs/symptoms of bleeding and infection
 4) continue to assess Mr. S. of his understanding of his
condition, educate him as needed, and what is being
done to help him
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Ongoing Assessments
 Assess for Desired Therapeutic Effects:
 HIV RNA assay (Viral Load) and CD4 levels, CBC,
Hepatic and Renal Function, Lipids, Amylase, Glucose
remain WNL
 Tolerate activities of daily living (ADL’s)
 Absence of signs and symptoms of Infection
 Watch for Adverse Effects:

n/v/d, anorexia, cramping, mental changes, pain, jaundice,
dark urine, rash, blistering,
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Neuman System Model
 Discuss the stressors, Basic Structure and
protective concentric rings – Flexible and
Normal Line of Defense and Lines of
Resistance.
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Follow Up Next Day
 Mr. S. tolerated a transfusion of 2 Units of PRBC’s, and
the AM lab results showed his H&H has increased to
12/32. His WBC’s and Platelets remain low.
 He is avoiding the use of a razor and is careful to avoid
falling/injuring himself by calling for assistance when
getting up. He is taking up to 900cc’s of PO fluids each
shift and making adequate urine.
 The hospital staff is maintaining Reverse Isolation to
prevent exposing Mr. S. to infections.
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Next Day Continued
 The Surgeon consulted with Mr. S.’s Attending MD
who recommended adding a Nonnucleoside Reverse
Transcriptase Inhibitor (NNRTI) to his medication
regimen and continue to monitor his lab values.
 The Nurse informs the Attending MD that Mr. S. is
compliant with his medications and has a good
understanding of his current condition, his vital signs
are stable (VSS), he is afebrile, and is not excessively
fatigued.
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3) Nonnucleoside Reverse
Transcriptase Inhibitors (NNRTI)
 efavirenz (Sustiva), a prototype drug
 600mg PO HS Daily on empty stomach.
Adverse Effects:
 Common: Rash, fever, nausea, diarrhea, headache,
stomatitis, dizziness, sleep disorders, fatigue
 Serious: Paresthesia, hepatotoxicity, neutropenia,
Stevens-Johnson Syndrome, CNS toxicity.
 Contraindications: teratogenicity- avoid use in the
pregnant pt., use reliable birth control methods.
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How Do NNRTI’s Work?
 NNRTI’s bind directly to the HIV viral
enzyme reverse transcriptase, blocking
RNA & DNA dependant DNA
polymerase which disrupts its function.
This drug action prevents viral DNA
construction.
• Pharmacology for Nurses 3rd Ed. 2011
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Mr. S. Post Op Day 5
 Mr. S. is progressing in his rehabilitation s/p
Lt. TKR. He is ambulating 200 feet in the
hall 2X daily using his walker and stand-by
assistance only. He knows to take rest
between each activity because of the
possible side effects of ART along with the
fatigue due to being Hospitalized (surgery,
pain, prolonged bed rest, muscle wasting,
sleep disturbance, etc).
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th
5
Day Continued
 Lab Values:
 H&H: 12/31
 WBC’s: 5
 Platelets: 45,000
 Viral Load: Not detectable
 CD4 Count: 800/ml
 Liver & Kidney Function Tests:
Within Normal Limits (WNL)
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Attending MD Had Considered
adding a Fusion Inhibitor (FI)
 Enfuvirtide (Fuzeon)
 SubQ 90mg BID
Adverse Effects:
 Common: Pain and inflammation at injection site, nausea,
diarrhea, fatigue, abdominal pain, cough, dizziness,
musculoskeletal symptoms, pyrexia, rash, upper respiratory tract
infections
 Serious: Hypersensitivity, myocardial infarction, neutropenia,
thrombocytopenia, nephrotoxicity, hepatotoxicity.
 Contraindications: Hypersensitivity, lactation.
• Pharmacology for Nurses 3rd Ed. 2011
• Prentice Hall Nurse’s Drug Guide 2009
35
Fuzeon Drug Action
 Interferes with entry of HIV-1 virus into the host T4
lymphocyte cell by inhibiting fusion or linkage of the
virus to the CD4 receptor.
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Attending MD continued
MD decides to hold off starting the F.I.
at this time due to stable CD4 cell
counts and low viral load. He will
continue to monitor labs on an outpatient basis along with office visits by
Mr. S. every 3 months for now.
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A Newer HIV Drug Class:
Integrase Inhibitors
 Raltegravir (Isentress) blocks HIV integrase,
preventing HIV from inserting its genes into
uninfected host DNA.
 Dosage: 400mg PO BID
 Similar Common and Serious Adverse Effects as the
Fusion Inhibitors including myopathy, (nephrotoxicity
less common).

Pharmacology for Nurses 3rd Ed. 2011
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Home
 Mr. S. is to be discharged home Post Operative Day 6.
His partner is taking off work for 2 weeks to assist him
with ADL’s. An RN from the VNA will visit to remove
the staples from his Knee on Post Op. Day 10. He has
an appointment with his surgeon in 2 weeks for follow
up.
 What important points need to be covered in the
Discharge Instructions by the Nurse prior to going
home?
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Discharge Instructions Include:
 Monitor for symptoms of hypersensitivity or
anaphylactic-type reactions
 Monitor VSS, observe for signs/symptoms of infection,
hypotension
 Watch for mouth ulcers or white patches
 Comply with scheduled lab draws. (They determine
the effectiveness of HAART and/or drug toxicity)
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Discharge Instructions Cont’ed
 Drug-Drug and Drug-Food interactions (dosing times,
no skipping, OTC’s,)
 Immediately report severe abdominal pain or
distension, n/v or fever
 Support the immune system (adequate rest, sleep,
nutrition, hydration)
 Report numbness/tingling of extremities, using
caution to avoid injury
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Discharge Instructions Cont’ed
 Multidisciplinary Care: Nutritionist,
Social Worker, Physical Therapist, etc.
PRN
 Review client’s level of understanding
regarding the use and effect of
medications.
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Nurse Follow Up
Discharge Nurse asks client about
HAV, HBV & HCV status. Patient
denies history, then nurse confirms
via a chart check for up-to-date
Immunizations.
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Hepatitis A, B & C
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Viral Hepatitis
 Hepatitis A Virus(HAV)-acute disease (not chronic)
 Oral/Fecal Transmission-rare fatalities, few patients
develop severe liver disease
 HAV vaccine (Havrix, VAQTA). 2 step vaccination
process-booster giver 6-12 months after initial dose
 Almost 100% immunity results, lasting 5-8 years, up to
20 years.

Pharmacology for Nurses 3rd Ed. 2011
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Hepatitis B
 Hepatitis B Virus (HBV), a chronic disease
 Transmission via Blood/Body Fluid
 Greater morbidity and mortality rate than HAV. 10%
develop chronic disease (cirrhosis/Liver CA)
 High Risk factors: IVDU, MSM, Sex with infected
partner, health care workers, perinatal & child to child.
 HBV vaccination (Recombivax HB, Engerix-B): 3 doses
confer up to 90% of clients with protection if exposed
(Twinrix contains both HAV & HBV vaccine).
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Hepatitis C Virus (HCV)
 Blood/Body Fluids are primary mode of transmission
 70% develop chronic hepatitis, 1/3 of these clients go
on to develop end stage cirrhosis
 Nearly 50% of all clients infected with HIV-AIDS are
co-infected with HCV
 No vaccine yet available
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Chronic Hepatitis C Therapy
When the chronic disease becomes
active or symptoms appear drug
treatment is initiated with:
 Interferons
 NonInterferons
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INTERFERONS
 Interferon alfacon-1 (Infergen): SubQ 9mcg three
injections/week for 24 weeks
 Interferon alfa-2b: 3 million international units SubQ
3 X per week (PEG 1 X week)
 Common Adverse Effects: Flu-like symptoms,
myalgia, fatigue, H/A,
anorexia, diarrhea
 Serious Adverse Effects: Myelosuppression,
thrombocytopenia, suicide ideation
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NonInterferons & Combinations
 Adefovir dipivoxil (Hespera): 10mg PO daily
 Lamivudine (Epivir HBV): 150mg PO BID
 Robetron: Ribavirin 200mg PO 5-6 capsules
Daily & Interferon alfa 2b Subq 3 million
International Units TID/week
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 NonInterferons:
Adverse Effects:
Common asthenia (weakness), H/A, nausea,
dizziness, fatigue, nasal disturbances (lamivudine)
 Serious: Nephrotoxicity & lactic acidosis
(adenfovir); pancreatitis, hepatomegaly with
steatorrhea (lamivudine); cardiac arrest, hemolytic
anemia, apnea (ribaviron).
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New Therapy for HCV
 Incivek, a Protease Inhibitor
 In Phase 3 of a clinical research study, in combination
with Pegylated-Interferon and Ribaviron, Incivek
increased the sustained viral response (SVR, an
undetectable level of HCV 24 weeks after completion of
drug therapy) from 44% to 79% for a group of 1095
patients.

Sutter Health June 23, 2011
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Herpesvirus Family
 HSV 1 : facial/oral
 HSV 2 : genital
 Cytomegalovirus(CMV):
multisystem affects for
immunocompromised clients
 Varicella-zoster virus (VZV):
chicken pox & shingles
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Herpesvirus Family Continued
 Epstein-Barr virus:
mononucleosis/Burkitt’s lymphoma
 Herpesvirus 6:
roseola in children, hepatitis or encephalitis
for immunocompromised clients
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Acyclovir (Zovirax)
 Prototype Drug
 For the Immunocompromised patient (ex.: AIDS,
geriatric) who develops Herpes Zoster: 800mg PO 5 X
daily X 7-10 days. Can prevent or lessen early
symptoms (pain, tingling, itching) and lessen the later
outbreak of herpes rash and blisters (Shingles).
 topical preparations are less effective
 IV: 5-10 mg/kg q8h X 7-14 days
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Acyclovir (Zovirax) Cont’ed
 Adverse Effects with topical/oral/IV-
generally minimal/infrequent:
 N/V/D, H/A, fatigue, dizziness, tremors,
confusion, pain/inflammation at injection site
 Serious: seizures, acute renal failure,
thrombocytopenic purpura.

Prentice Hall Nurse’s Drug Guide 2009
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References
 Adams, P., Holland, L., Urban, C., Pharmacology for Nurses, A
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Pathophysiological Approach, 3rd Ed., 2011, Pearson Education, Inc.
Nursing 2008 Drug Handbook, 28th Ed., Wolters Kluwer/Lippincott
Williams & Wilkins
Prentice Hall Nurse’s Drug Guide 2009, Wilson, B., Shannon, M.,
Shields, K.
Tulane University, Department of Microbiology and Immunology, Big
Picture Book of Viruses: Retroviridae
Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. 2007, Quality and
safety education for nurses, Nursing Outlook, 55(3)122-131.
http://www.sutterhealth.org/about/news/news11_CPMC-New-DrugHelps-Hepatitis-C-Patie... Retrieved 7/3/11
Davis’s Drug Guide for Nurses, Deglin, J., Vallerand, A., Sanoski, C., 12th
Ed., 2011
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