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1. GPO vir-Z 250 ?1. GPO vir-Z 250

1. AZT( Zidovudine ) 250 mg

2. 3 TC( Lamivudine) 150 mg

3. NVP (Nevirapine) 200 mg

1. , , , , . . Thai Pharm

Health Sci J 2009;4(2):202-207 2. . . 2553

(National guides on HIV/AIDS Diagnosis and treatment Thailand 2010). ;2553

3.http://dpc 9.ddc.moph.go.th/napha 9/ sudya.html #8 :Accessed May 02, 2013

2. GPO vir s 40 ?1. GPO vir S30 S40

GPO VIR S40 - nevirapine : 2-3 ,

1-2 18 1-3 - lamivudine : - stavudine : 2-6

stavudine 1

CD4+

CD4+ 50 copies/ 6

CD4+ 3-4 CD4+ 100-150 /

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2

3. ARV ?

NRTIs(Nucleoside Reverse

Transcriptase Inhibitor)

NNRTIs(Non Nucleoside Reverse Transcriptase Inhibitor)

PIs(protease inhibitors)

AZT (Zidovudine)d4T ( Stavudine )3TC ( Lamivudine)

ddI ( Didanosine)ABC ( Abacavir)

TDF ( Tenofovir )FTC ( emtricitabine)ddC ( Zalcitabine)

NVP ( Nevirapine)

EFV ( Efavirenz )

DVL ( Delavirdine )

Etravirine (ETR)

IDV ( Indinavir )RTV ( Ritronavir )SQV ( Saquinavir )

LPV/RTV (Lopinavir/Ritronavir )NFV ( Nelfinavir )ATV ( Atazanavir )

APV ( Amprenavir)FPV ( Fosamprenavir )

Integrase inhibitors FIs

(fusion inhibitor)

CCR5-antagonist

- Raltegravir (RAL ENF ( Enfuvirtide) - Maraviroc

Vicriviroc,

1. NRTIs side chain nucleosides (thymidine,adenosine, cytidine) phosphorylation mono-,di-, triphosphate compound HIV-RT(inhibitory competitor) DNA (chain terminator)

(monotherapy) 0.3-0.7 log10 10 100,000 . . nucleoside RTI monontherapy ( AZT

ddI) 10,000 . .

2.NNRTIs NNRTIs noncompetitive nativenucleotides HIV-1 RT (downsteam) catalytic site NNRTIs metabolize NNRTIs 1-2

(favorable adherence)

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3.PIs HIV-1 protease enzyme HIV-1 2 (symmetrical isomer) (amino acids) 99 gag-polpolypeptide precursor immature HIV-1 mature infectious

4.FIs Glycoprotein HIV-1 2 gp120 gp41 gp120 CD4 gp41 fusion

transcription translation gp41 trimer trimer-hairpin hydrophobic grooves HR1 3 stable six-helix bundle fusion fusion pore

hairpin fusion5. CCR5-antagonist CCR5 receptor CD4+ cell HIV

4.Guideline AIDS

1. . .2553National Guidelines on HIV/AIDS Diagnosis and Treatment:Thailand 2010

2. Antiretroviral therapy for HIV infection in adults and adolescents Recommendations for a

public health approach 2010 revision : World Health Organization 2010

3. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

Source: 2012 The Department of Health and Human Services (DHHS) Antiretroviral Therapy Guidelines.

AIDS Info (aidsinfo.nih.gov)

4. Antiretroviral Treatment of Adult HIV Infection: 2012 Recommendations of the International

Antiviral Society-USA Panel

5. Opportunistic Infections Bacteria, Viral, Fungal

1.Candidiasis mucosal candidiasis (oropharyngeal candidiasis, cervicovaginal candidiasis,esophageal candidiasis diaper dermatitis ; )

Primary prophylaxis ;

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Secondary prophylaxis

mucosal candidiasis /

ADR : Fluconazole: N/V, GI side effect

Clotrimazole:

,

Nystatin: N/V, Diarrhea

Itraconazole: N, V

2.Pneumocystic carinii pneumonia (PCP)

Pneumocystic (jiroveci) carinii CD4 < 200/mm3 1-2 crepitation

(congestive heart failure) (acute respiratory distress syndrome, ARDS)Lab

- CD4 < 200/mm3 - Arterial blood gas - A-a gradient

- Lactate dehydrogenase (LDH)

Bronchoveolar lavage (BAL)

PCP: Categorized

by PaO2 and A-a gradient

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*** 21 ***

Corticosteroid :

PaO2

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Primary prophylaxis

CD4< 200 2 wk AIDS-defining illness ( ) sulfa Dapzone 100 mg OD ( arylamine

) CD4 > 200 3

Secondary prophylaxis

Primary CD4 > 200 3

3.Cryptococcal Meningitis

Cryptococcus neoformans 5-8% prevalence in HIV-infected patients in developedcountries before widespread use of effective ART (14.31% in Thailand 3 )

Primary prophylaxis

(Fluconazole 400 mg PO q wk ( ***))

Secondary Prophylaxis

induction consolidation

- Fluconazole 200 mg PO OD ***

- Amphotericin B 0.6-1 mg/kg IV 1-3 times/wk (multiple relapse on azoles)

- Itraconazole cap 200 mg PO od

CD4 100-200/mm3 6

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4.Cytomegalovirus (CMV)

retinitis

induction thx (BID) --> maintenane(OD) 2-3 wk

Primary prophylaxis

Secondary prophylaxis

Valganciclovir 900 mg PO OD

Ganciclovir 5 mg/kg IV Ganciclovir intravitreous 200 g 1-2

CD4 > 100-150 6

5.Toxoplasmic encephalitis (TE) Toxoplasmosis

Toxoplasma gondii (intracellular protozoan) hemiparesis, CN plasy

stiff neck conscious

pyrimethamine 200 mg -->50 -100 mg/d+ sulfadiazine 1-2 g 4 + folinic acid 10mg/day 6

pyrimethamine clindamycin 300-450 . 4

TMP-SMX 5-10 mg/kg/day TMP IV/PO

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Pyrimethamine clindamycin 600 mg 6-8 ( sulfadiazine )Pyrimethamine azithromycin 1,000-1,250 mg/day

Primary prophylaxis

CD4 < 100 IgG TMP/SMX SS 2 tab OD (prophylaxis PCP ) sulfa Dapzone 50 mg/day + pyrimethamine 50 mg/wk + folinic acid 25 mg/wk PO

CD4 > 200 3 Secondary prophylaxis

Sulfadiazine 0.5 g PO qid + pyrimethamine 50 mg/day + folinic acid 10 mg/day PO

CD4 > 200 6

6.TB

1) Rifampicin CYP450

efflux multi-drug transporter P-glycoprotein NNRTIs PIs 2) IRIS

IRIS IRIS

3) 4) 5)

Treatment of tuberculosis

2IRZE/4-7IR(I) 5-8 mg/kg (300 mg)

(R) 10 mg/kg (450-600 mg)

(E) 15-20 mg/kg (800-1,200 mg)(Z) 20-30 mg/kg (1,000-1,500 mg)

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S 10-15 mg/kg ( 1,000 mg) IM OD R R R Pls

2 9 DOT ( . . .) pyridoxine (B6)25-50 mg INH

rifampicins 2 IE OD 18 IE quinolone ofloxacin 12-18

Kanamycin 15 mg/kg (Max 1,000 mg) IM Amikacin 15 mg/kg (Max 1,000 mg) IM Ethionamide 15 mg/kg (500 -750 mg/day)

PO 2-3 Cycloserine 10 mg/kg (500 -750 mg/day)

PO 2-3 PAS(Para-aminosalicylic acid) 150 mg/kg (8,000-12,000 mg/day) PO 2 Ofloxacin 600 -800 mg/day Levofloxacin 500 -750 mg/day Moxifloxacin 400 mg/day

(Multi Drug ResistantTB: MDR-TB) INHrifampicin 3-4 1

(Extensively Drug Resistant TB: XDR-TB)

7.Mycobacterium Avium Complex (MAC)

CD4 < 50 cell/mm3 M. avium(95%) & M. intracellulare

GI 2

: acid-fast stain --> ( ) Bactec s.

Clarithromycin 500 mg 2 +ethambutol 15-25 mg/kg/dAzithromycin 500-600 mg/d + ethambutol 15-25 mg/kg/d

CD4 >100 6 MAC 12 Primary prophylaxis

CD4 < 50 CD4 Clarithromycin 500 mg PO BID Azithromycin 1000 - 1250 mg/wk

CD4 > 100 3

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Secondary prophylaxis

CD4 100 / . . MAC12 MAC

8. Histoplasmosis Penicillosis

Histoplasma capsulatum Penicillium marneffei = systemic mycosespenicilliosis -->papulonecrotic skin lesions histoplasmosis -->

papules, nodules

Induction phase : Amphotericin B 0.7 mg/kg/day 1-2 Consolidation phase : itraconazole 400 mg/day 10

Primary prophylaxis

CD4< 100Itraconazole 200 mg OD** ( cryptococcosis )

CD4 > 100 6 Secondary prophylaxis

Primary

CD4 > 100-150 6 **capsule solution

9. Herpes simplex and Herpes zoster

Herpes simplex ( )

Acyclovir 400 mg 3 famciclovir 250 mg 3 valacyclovir 1 g 2 5-10 5 14 Herpes zoster ( )

Acyclovir 800 mg 5 famciclovir 250 mg 3 valacyclovir 1 g 3 5-10

10. OIs GI

: 1 fresh smear2 Acid-fast stain

3 , .... Quinolones (norflox.) +metronidazole( Giardia , Entamoeba , diarrhea ATB)

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11 Cryptosporidiosis

Cryptosporidium epigastric cramping ( 10 /24 .)

antibiotics Erythromycin,Spiramycin, Paramomycin , ni antimotility agents loperamide 4 mg

diphenoxylate 5 mg

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6. Gold Standard Cryptococcal Meningitis 1. Lumbar puncture

- Intracranial pressure (ICP) - glucose- protein - +ve Cryptococcal Ag

- WBC 2. Lab

- CD4 < 100/mm3

- CSF: dark halo (india ink:60-80%)

- CSF: ICP, WBC < 20, / protein, / glucose, Crypto Ag > 1:8 (>95%)

7. Guideline AIDS Regimen 8. . regimen

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1 1 d4T( Stavudine ) + 3TC ( Lamivudine)+ NVP( Nevirapine) ( GPO-VIR ) 2 2.1 d4T( Stavudine ) + 3TC( Lamivudine) + EFV ( Efavirenz ) NVP(Nevirapine)

2.2 AZT(Zidovudine) + 3TC( Lamivudine) + NVP(Nevirapine) d4T(Stavudine) d4T < 50 copies/ml

d4T GPO-VIR S40 GPO-VIR S30 d4T, 3TC NVPd4T 15 20 mg 12

2.3 AZT + 3TC + EFV NVP d4T 3 3.1 d4T + 3TC + IDV / RTV

3.2 AZT + 3TC + IDV / RTV

9. New case ?CD4 CD4 3-6

*** -

- AZT - NVP (antihistamine)

( ) -

- AZT - NVP (antihistamine)

( )

*** (Drug interaction)

***

( 30 ) IDV

RTV SQV ( 2-8 ) RTV

(25 ) 1 SQV 3 2