Clinical management of drug interaction with antiretroviral agents

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Drug interactions and antiretroviral drug monitoring

Owing to the improved longevity afforded by combination antiretroviral therapy (cART), HIV-infected individuals are developing several non-AIDS-related comorbid conditions. Consequently, medical management of the HIV-infected population is increasingly complex, with a growing list of potential drug-drug interactions (DDIs). This article reviews some of the most relevant and emerging potential interactions between antiretroviral medications and other agents. The most common DDIs are those involving protease inhibitors or non-nucleoside reverse transcriptase inhibitors, which alter the cytochrome P450 enzyme system and/or drug transporters such as p-glycoprotein. Of note are the new agents for the treatment of chronic hepatitis C virus infection. These new classes of drugs and others drugs that are increasingly used in this patient population represent a significant challenge with regard to achieving the goals of effective HIV suppression and minimization of drug-related toxicities. Awareness of DDIs and a multidisciplinary approach are imperative in reaching these goals.

Using computer-based monitoring and intervention to prevent harmful combinations of antiretroviral drugs in the New York State AIDS Drug Assistance Program

BACKGROUND

Despite the growing number of HIV-infected people and the acknowledged complexity of HIV therapy, there are no standard safeguards in the outpatient setting against dangerous antiretroviral (ARV) therapy combinations in the publicly financed arena.

METHODS

Using quarterly pharmacy claims data from the New York State AIDS Drug Assistance Program, a three-phase approach was developed: The extent of contraindicated ARV combinations was ascertained; prescriber alerts were developed; and, finally, the reimbursement of contraindicated ARV combinations was blocked at pharmacy. ARV dosages, the number of ARV medications in a regimen, clinical adequacy of the regimen, medication claim denials, clinician adjudication, and subsequent clinician prescribing patterns were analyzed.

RESULTS

For the 27-month study period (October 1, 2006-December 31, 2009), 112,383 ARV regimens involving 396,303 ARV medications for 25,463 unique recipients were individually analyzed. A total of 1,089 interventions occurred; denials and interventions increased per quarter from a baseline of 129 to 217 by the study's end. All contraindicated combinations referred for adjudication during the study were upheld. More than 88.3% (range, 87.1% to 89.9%) of regimens per quarter were consistent with effective ARV as promulgated by current guidelines. The targeted dissemination of ARV drug interaction safety alerts to previous prescribers of contraindicated combinations during the first year of the review curtailed the practice by 77.3%.

CONCLUSION

A systems-level intervention can be used on a state level to reduce ARV contraindicated medication errors in the outpatient setting through a coordinated approach of prescriber clinical education and electronic pharmacy and billing systems and provides an effective safety and quality monitoring model.

Recognition and management of significant drug interactions in HIV patients: challenges in using available data to guide therapy

Combination antiretroviral therapy (cART) has improved survival rates in HIV-infected patients; however, patients now experience comorbidities that require pharmacological intervention, thereby increasing the risk of drug-drug interactions (DDIs). HIV protease inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and the CCR5 antagonist maraviroc are primarily metabolized via the cytochrome P450 (CYP) system and are prone to pharmacokinetic interactions.(1,2) This article addresses some key challenges that prescribers face when using available drug interaction-data resources in making day-to-day clinical decisions.

Adverse drug reactions to nonnucleoside reverse transcriptase inhibitor-based antiretroviral regimen: a 24-week prospective study

BACKGROUND

Few studies have addressed the issue of adverse drug reactions with non-protease inhibitor (PI)-based antiretroviral therapy (ART) in resource-constrained settings. We studied prospectively the incidence of adverse drug reactions with generic ART among our patients.

METHODOLOGY

A total of 100 HIV-infected individuals were recruited. Patients received nevirapine (NVP) or efavirenz (EFV) with lamivudine (3TC) and zidovudine (ZDV)/stavudine (d4T). They were followed for 6 months for evidence of adverse drug reactions.

RESULTS

The mean CD4 count was 114.09 +/- 60.07 cells/mm(3) (range, 12-232 cells/mm(3)). Transient gastrointestinal symptoms were most frequent. Fourteen individuals (12 receiving ZDV/d4T, 3TC, NVP and 2 receiving ZDV/d4T, 3TC, EFV) developed skin rash. Among patients receiving NVP, 25.7% developed grade 1 hepatotoxicity. Three patients had numbness in both lower limbs. Among those individuals who received EFV, 32.3% individuals had central nervous system (CNS) symptoms in the form of insomnia, vivid dreams, dizziness, and drowsiness.

CONCLUSION

As the developing world increasingly uses generic ART, the clinician must be constantly vigilant for treatment-related adverse events.