You admit a 34-year-old woman living with HIV to the ICU after a motor vehicle accident. She sustained blunt abdominal trauma with small bowel injury, requiring removal and re-anastomosis of a section of jejunum. Her CD4 T-cell count 3 weeks before the accident was 273 cells/mL. The surgical team recommends strict avoidance of oral intake and initiating total parenteral nutrition while her bowel heals. The patient is currently taking a three-drug regimen to treat her HIV infection, including dolutegravir, tenofovir, and emtricitabine.
What should be done about HIV treatment while the patient remains nil per os?A. Stop all HIV medications simultaneously
Correct Answer: A
Antiretroviral therapy is life-prolonging in people living with HIV. Research has shown poorer long-term outcomes among people undergoing planned or unplanned treatment interruptions. Nevertheless, there are occasional situations in which a treatment interruption is unavoidable, such as when a patient experiences a severe or life-threatening toxicity or unexpected inability to take oral medications. In this scenario, it is recommended that all antiretroviral medications be stopped simultaneously and restarted together when the patient is again able to take oral medications. Unfortunately, there are currently no FDA-approved intravenous preparations of antiretroviral medications. Certain antiretroviral drugs have long half-lives, including the nonnucleoside reverse transcriptase inhibitors (NNRTIs) efavirenz, etravirine, and rilpivarine. When a patient is taking three-drug antiretroviral regimen containing one of these medications, stopping all antiretroviral medications at once could lead to effective monotherapy with the drug with the longest half-life (often an NNRTI), promoting HIV drug resistance. Because this patient’s recent CD4 T-cell count is above 200 cells/mL, antibiotic prophylaxis against opportunistic infections is not indicated. Owing to the complexities of managing patients taking antiretroviral medications with differing half-lives, medication interactions, and increased susceptibility to infections, infectious diseases consultation is recommended whenever discontinuation of antiretroviral medications is considered in a person living with HIV.
Mwanamke mwenye umri wa miaka 34 aliyejeruhiwa na virusi vya Ukimwi amepelekwa katika chumba cha wagonjwa mahututi baada ya kuanguka kwenye gari. Alipata jeraha la tumbo lenye umbo la mdomo mdogo, likihitaji kuondolewa na kuunganishwa tena kwa sehemu ya jejunum. Idadi ya chembe za T za CD4 zilikuwa 273 kwa wiki moja kabla ya ajali. Timu ya upasuaji inapendekeza kuepuka kabisa ulaji wa mdomo na kuanzisha lishe ya jumla ya parenteral wakati utumbo wake unapona. Mgonjwa huyo kwa sasa anapata dawa tatu za kutibu maambukizi yake ya Ukimwi, ikiwa ni pamoja na dolutegravir, tenofovir, na emtricitabine. Ni nini kinachopaswa kufanywa kuhusu matibabu ya HIV wakati mgonjwa bado ni nil per os? "Usimalize dawa zote za HIV kwa wakati mmoja, kwa sababu ""Tiba ya Antiretroviral inaongeza maisha ya watu wanaoishi na HIV.""" Utafiti umeonyesha matokeo mabaya zaidi ya muda mrefu miongoni mwa watu wanaopitia mapumziko ya matibabu yaliyopangwa au yasiyopangwa. Hata hivyo, kuna hali za mara kwa mara ambapo kusimamishwa kwa matibabu ni lazima, kama vile wakati mgonjwa anapopata sumu kali au hatari ya maisha au kutokuwa na uwezo wa kuchukua dawa za mdomo. Katika hali hii, inashauriwa kwamba dawa zote za antiretroviral zisimamishwe kwa wakati mmoja na kuanza tena pamoja wakati mgonjwa anaweza tena kuchukua dawa za mdomo. Kwa bahati mbaya, kwa sasa hakuna dawa za antiretroviral zilizokubaliwa na FDA kwa ajili ya kutiwa ndani ya mshipa. Dawa za anti-retroviral zina muda mrefu wa nusu ya maisha, ikiwa ni pamoja na non-nucleoside reverse transcriptase inhibitors (NNRTIs) efavirenz, etravirine, na rilpivarine. Wakati mgonjwa anapotumia dawa tatu za antiretroviral zenye moja ya dawa hizi, kuacha dawa zote za antiretroviral mara moja kunaweza kusababisha monotherapy yenye ufanisi na dawa yenye nusu ya maisha ya muda mrefu (mara nyingi NNRTI), kukuza upinzani wa dawa za HIV. Kwa sababu idadi ya hivi karibuni ya CD4 T- seli ya mgonjwa ni juu ya 200 seli kwa ml, prophylaxis ya antibiotic dhidi ya maambukizo ya fursa haionyeshwi. Kwa sababu ya utata wa kusimamia wagonjwa wanaotumia dawa za antiretroviral na nusu ya maisha tofauti, mwingiliano wa dawa, na kuongezeka kwa unyeti kwa maambukizo, ushauri wa magonjwa ya kuambukiza unapendekezwa wakati wowote kusimamishwa kwa dawa za antiretroviral kunazingatiwa kwa mtu anayeishi na HIV.