First guidelines for opportunistic infections

Highly active antiretroviral therapy (HAART) has reduced the incidence of opportunistic infections (OIs) among HIV-infected patients with access to adequate medical care. Unfortunately, some patients in the United States and elsewhere do not have access to sufficient care. Others do not have a sustained response to antiretroviral agents for many reasons, including poor adherence. In these two patient groups, OIs will continue to cause significant morbidity and mortality.

The Centers for Disease Control & Prevention, National Institutes of Health, and Infectious Diseases Society of America/ HIV Medical Association recently developed a set of evidence-based guidelines on the treatment of OIs in HIV-infected adults and adolescents. This marks the first time that comprehensive OI treatment guidelines have been published, commented Alice Pau, Pharm.D., an author of the guidelines and a clinical pharmacy specialist in the Office of Clinical Research of the National Institute of Allergy and Infectious Diseases at NIH.

"Treating Opportunistic Infections Among HIV-infected Adults and Adolescents" was published in the Dec. 17, 2004, issue of Morbidity and Mortality Weekly Report (MMWR). It is available on-line at: http:// http://www.cdc.gov/mmwr/PDF/RR/RR5315.pdf Its companion document, "Treating Opportunistic Infections Among HIV-Exposed and -Infected Children," was published in the Dec. 3, 2004, issue of MMWR and is available on-line at: http:// http://www.cdc.gov/mmwr/PDF/RR/RR5314.pdf.

"The document includes evidence-based guidelines for the treatment of 28 OIs seen in HIV-positive patients," said Pau. Each OI section contains information on clinical manifestations, diagnosis, treatment recommendations, monitoring and adverse events, management of treatment failure, how and when to discontinue therapy, and special considerations during pregnancy.

"These treatment guidelines address a few more disease states compared with previous guidelines that focused on prevention," said Jennifer Cocohoba, Pharm.D., an assistant clinical professor in the department of clinical pharmacy at the University of California at San Francisco School of Pharmacy. Both she and Pau cited hepatitis B virus (HBV) infection as an example.

The authors state that in HIV-infected patients who are HAART-naïve and require antiretroviral therapy, lamivudine (Epivir, GlaxoSmithKline) 150-mg tablets taken twice daily are commonly used to treat HBV infection. For those who are lamivudine-experienced and require HAART, the authors said that tenofovir (Viread, Gilead) 300-mg tablets taken once daily in conjunction with a fully suppressive antiretroviral regimen are considered by certain specialists to be the optimal choice for the treatment of HIV and HBV infection.

"A lot of information that is of particular interest to practicing pharmacists is nicely summarized in the tables at the end of the document," Cocohoba said. "For example, Table 8 discusses the drug-drug interactions among the agents used to treat OIs and the drugs used for HAART."

One of the recommendations in the table is to decrease the dose of clarithromycin by 50%, or use an alternative agent, in those taking atazanavir (Reyataz, Bristol-Myers Squibb).

Cocohoba explained that an important area for pharmacists to focus on is that of drug interactions, because so many medications are being administered at one time to these patients. "Often," she said, "the pharmacist is the one others look to for the prevention of drug-drug interactions, particularly if the drugs being administered are not used very often."