Table 17d. Antiretroviral Therapy-Associated Adverse Effects and Management Recommendations—Hematologic Effects Adverse Associated Onset/Clinical Effects ARVs Manifestations Anemia*
Principally ZDV
Onset:
Estimated Frequency HIV-exposed
Variable, weeks to newborns: months Severe anemia uncommon, but Presentation: may be seen co Most commonly asymptomatic or incident with mild fatigue, pal physiologic Hgb nadir lor, tachypnea Rarely, congestive HIV-infected heart failure children on
ARVs: 2–3 times more common with ZDV-containing regimens Less frequent with currently recommended dosing of ZDV
Neutrope- Principally nia* ZDV
Onset:
Risk Factors
Management
HIV-exposed newborns:
HIV-exposed new borns:
• Premature birth • In utero exposure to ARVs • Advanced mater nal HIV disease • Neonatal blood loss • Concurrent ZDV + 3TC neonatal prophylaxis
Monitor CBC at birth.
HIV-exposed newborns:
• Underlying he moglobinopathy (sickle cell dis ease, G6PD defi ciency) • Poorly controlled HIV • Marrow-toxic drugs (e.g., TMP SMX, rifabutin) • Iron deficiency
agents are available.
HIV-infected children HIV-exposed newborns: on ARVs: No established threshold
Rarely require intervention unless Hgb is <7.0 gm/dL Consider repeat CBC at or anemia is associated with symptoms. 4 weeks for neonates who are at higher risk Consider discontinuing ZDV if 4 weeks or more of (e.g., born prema 6-week ZDV prophylaxis turely, known to have regimen are already com low birth Hgb). HIV-infected children pleted (see† Perinatal Guidelines ). on ARVs:
HIV-infected children on Avoid ZDV in children HIV-infected chil with moderate to severe ARVs: dren on ARVs: anemia when alternative Discontinue non-ARV mar
Variable
HIV-exposed newborns:
HIV-exposed newborns:
Presentation:
Rare
• In utero exposure to ARVs
Most commonly asymptomatic
Prevention/ Monitoring
row-toxic drugs if feasible.
Monitor CBC 3–4 times Treat coexisting iron defi per year as part of rou ciency, OIs, malignancies. tine care. For persistent severe ane mia thought to be associ ated with ARVs: change to a non-ZDV-con taining regimen; consider a trial of erythro poietin.
Monitor CBC 3–4 times for intervention; some exper year as part of rou perts would consider HIV-infected using an alternative NRTI • Concurrent ZDV tine care. children on for prophylaxis if ANC + 3TC neonatal ARVs: <500 cells/uL or, if 4 prophylaxis 9.9%–26.8% of weeks or more of 6-week children on ARVs, HIV-infected chil ZDV prophylaxis regimen depending upon dren on ARVs: are already completed, the ARV regimen • Poorly controlled discontinuing ARV prophylaxis entirely (see Peri Higher with ZDVHIV infection natal Guidelines†). containing regi• Marrow-toxic mens HIV-infected children on drugs (e.g., TMP ARVs: SMX, ganciclovir, hydroxyurea, ri • Discontinue non-ARV fabutin) marrow-toxic drugs if feasible. • Treat coexisting OIs, ma lignancies. For persistent severe neu tropenia thought to be as sociated with ARVs: change to a non-ZDV-con taining regimen; consider a trial of G-CSF.
Guidelines for the Use of Antiretroviral Agents in Pediatric Infection
106