Rx Care

AIDS guidelines feature newest antiretrovirals

Healthcare professionals who treat those with HIV infection or AIDS are regularly confronted with complex therapeutic challenges. Fortunately, they have new guidelines to which they can refer when addressing issues such as when to start antiretroviral therapy, which drugs are appropriate for the initial treatment of HIV infection, when the antiretroviral regimen should be changed, and which drugs should be substi- tuted if a therapeutic change is required.

The International AIDS Society (IAS)-USA antiretroviral panel recently completed the biennial update of its guidelines for the treatment of adult HIV infection. The guidelines, "Treatment of adult HIV infection: 2004 recommendations of the International AIDS Society-USA panel," were published in the July 14 theme issue of the Journal of the American Medical Association on HIV/AIDS.

Sufficient data exist to continue to recommend antiretroviral therapy initiation in those with CD4 cell counts below 350 cells/mcl but above 200 cells/mcl, the authors of the guidelines said. They pointed out that therapeutic regimens should be individualized. Initiation of therapy is generally not recommended for those with CD4 cell counts between 350 cells/mcl and 500 cells/mcl, advised the IAS-USA panel.

When compliance is expected to be good, a regimen that includes a nonnucleoside reverse transcriptase inhibitor (NNRTI) is often the regimen of choice, said the authors. Of the NNRTIs available, evidence favors efavirenz (Sustiva, Bristol-Myers Squibb), they said. For initial regimens that include a protease inhibitor (PI), the panel recommended a ritonavir-boosted PI.

The panel recommended zidovudine (Retrovir, GlaxoSmithKline) plus lamivudine (Epivir, GSK) or emtricitabine (Emtriva, Gilead Sciences); tenofovir (Viread, Gilead) plus lamivudine or emtricitabine; or emtricitabine plus didanosine (Videx, BMS) as double-nucleoside/nucleo- tide reverse transcriptase inhibitors (NRTIs) appropriate for use in an initial regimen. The authors advised that triple-NRTIs are no longer recommended for use as initial therapy, and initial four-drug regimens are also not recommended at this time.

According to the panel, when symptoms associated with a single antiretroviral agent do not resolve, or laboratory toxicity develops, single drug substitutions may be required. The authors recommended that all agents in the regimen be discontinued if toxicity cannot be attributed to a single agent or is severe enough to require discontinuation of therapy.

Careful attention to adherence is required in those who are infected with drug-susceptible virus and in whom the first antiretroviral regimen fails, cautioned the authors. If attempts to improve compliance fail, and viral load is determined to fall between 500 and 1,000 copies/ ml, resistance testing is appropriate, they continued.

The pharmacist's most important role in the management of HIV infection is monitoring for drug-drug interactions, because several are possible, said Jeff Julian, Pharm.D., pharmacy manager for StatScript Pharmacy in Kansas City, Mo. The pharmacist must also support the patient in being adherent to the antiretroviral regimen, he added, noting that adherence is crucial in the treatment of a condition such as HIV infection.

If a pharmacist receives a prescription written by a clinician who is not an HIV or infectious disease specialist, he or she should check to verify the proper drug selection and dosage, Julian advised. "If I see a script from a clinician I do not know, and I am not sure whether he or she is an HIV specialist, I will be a little more vigilant in checking dosage and drug selection than I would be if the prescription is from a physician I know has been treating HIV infection for a long time," he said.

Julian added that pharmacists should be well versed in the adverse effects associated with antiretroviral drugs, because they affect patient compliance. He recommended that they discuss these adverse effects with patients before the initiation of therapy, so that the patients know what to expect. For example, efavirenz is associated with drowsiness. He suggested counseling patients to take the drug about 30 minutes before bedtime, to minimize its effect on their lifestyle.

The guidelines are based on actual clinical data, so they provide a strong framework around which to build an individualized treatment regimen, Julian said. The panel that developed the guidelines included some of the preeminent HIV/AIDS experts in this country, which adds credence to the document as well, he concluded.

Charlotte LoBuono

Charlotte LoBuono. AIDS guidelines feature newest antiretrovirals.

Drug Topics

Aug. 9, 2004;148:16.