•
Refractory hyperlipedemia after treatment with lipid-lowering agents is indication to substitute the offending drug.
Decision checklist not to start or stop ARV drugs • Jaundice • Hg <6.5 gm/dl • Severe vomiting (not capable of taking food or medication) • Severe skin rash (vesicles, desquamations, mucosal involvement, conjunctivitis, systemic manifestations such as fever • ALT > 5 X upper limit • Fatigue, nausea, vomiting, hepatomegaly---- as manifestations of lactic A.
12.3 Some complications and their management: Nausea: • Seen with ZDV, ddI and PIs • Nausea due to antiretroviral medication must be actively managed, as it can potentially be a barrier for treatment adherence • Antiemetics such as metoclopramide, promethazine given half an hour before the antiretroviral dose up to three times daily may be helpful. If the nausea does not settle, refer for expert advice or consider changing ARV regimen (see Table 16). Rash: • Both nevirapine and efavirenz may cause skin reactions. This usually occurs within the first two months of treatment. Concomitant TB therapy may confound the situation as these drugs can cause similar adverse events. • Clinical assessment to rule out other causes of rash (Table 16). Enquire about systemic symptoms, and check the temperature in a patient presenting with a rash. • For nevirapine, liver function tests also need to be evaluated Abdominal pain: • Abdominal pain in a patient on antiretroviral treatment can be caused by a number of serious problems, and should never be ignored • Important causes include lactic acidosis, pancreatitis, hepatitis, and disseminated tuberculosis • Recommended investigations: liver functions, lipase, and serum lactate. (Refer for further investigations as needed) • Seek expert help and refer if you are unsure of the cause of the pain Acute pancreatitis: • Seen with ddI and d4T, particularly when used in combination (i.e.d4T+ddI). • Symptoms include peri-umbilical abdominal pain, nausea and vomiting • Diagnosis is confirmed by determining level of serum amylase • Management: discontinue all ARVs. Treatment is supportive– IV fluids, pain controls and NPO. • When all symptoms resolve restart ART with change to different NRTI (i.e. ZDV or ABC).
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