| Summary: | 碩士 === 國立成功大學 === 臨床藥學研究所 === 91 === Part 1. Highly active-retroviral therapy related metabolic complications
Background
Treatment of human immunodeficiency virus (HIV) infection has evolved dramatically during the past 5 years. Standard care with potent multidrug regimens has resulted in reduced morbidity and mortality among persons with HIV infection. Such advances, however, have been tempered by a body of reports of adverse events associated with highly active antiretroviral therapy (HAART). Of particular concern is the emergence of morphologic and metabolic abnormalities, often referred as HIV-related lipodystrophy syndrome. The HIV-related lipodystrophy syndrome is characterized by sustained changes in body fat distribution, often accompanied by metabolic disturbances such as hypercholesterolemia, hypertriglyceridemia and impaired blood glucose tolerance. Although many researches clearly suggest a role of protease inhibitors in the etiology of the HIV-related lipodystrophy syndrome, it can be observed in PI-naïve patients taking nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors.
Objective
To examine the temporal trends in serum total cholesterol, triglyceride, uric acid and glucose levels after initiation of HAART in HIV-infected patients.
Subjects
HIV-infected patients with a fixed HAART regimen for a minimum of 6 months.
Methods
We investigated retrospectively, among of HIV-infected patients followed in the outpatient clinic of Infectious Diseases, in National Cheng Kung University Hospital, from August 1 1997 through December 31 2002. Medical history, clinical and laboratory data were retrieved from medical records. The main outcome measure was the prevalence of hypercholesterolemia, hypertriglyceridemia, hyperuricemia, and hyperglycemia and the changes in serum total cholesterol, triglyceride, uric acid, and glucose levels from baseline levels at month 3, 6, 12, 18, 24, and 30 after the initiation of HAART.
Results
The study consisted of 100 patients, of whom 85 were male. A total of 61 patients received PIs containing regimen. Serum levels of total cholesterol, triglyceride and uric acid increased markedly during follow-up period. Total cholesterol increased by 37 mg/dL (P = 0.018) at month 30; Triglyceride increased by 57 mg/dL and 70 mg/dL (P = 0.001, 0.003) at month 18 and 30. Uric acid increased by 2.87 mg/dL at month 24 after the initiation of HAART. However, the changes of serum glucose levels were insignificant. The upsurges of serum uric acid and glucose in PI-treated patients were greater than those in PI-naïve patients.
Conclusion
We found there were increased levels of total cholesterol, triglyceride and uric acid in HIV-infected patients after using HAART. The patients who treated with PIs have a greater increase in serum uric acid levels, which is not mentioned in published articles. It deserves more prospective studies to reveal its clinical significance and associated risk factors. Patient with HIV infection on HAART should be monitored for metabolic disarrangements and carefully followed for possible long-term cardiovascular risk.
Part 2. Clinical service: Adherence to antiretroviral therapy in
HIV-infected patients
Background
Poor adherence to highly active antiretroviral therapy (HAART) has serious consequences for HIV-infected patients, including failure to prevent viral replication and an increased risk of developing viral resistance. Estimates of average rates of nonadherence to antiretroviral therapy range from 50% to 70%. Adherence rates of <80% are associated with a detectable viremia in a majority of patients. Treatment adherence can be measured by use of a variety of methods and these measures of adherence have different strengths and weaknesses in regard to practical application and identifying deficient adherence.
Objective
To provide pharmaceutical care and develop a medication adherence program providing education and counseling for HIV-infected patients.
Subjects
HIV-1 infected patients who agree to receive pharmacist’s counseling in the Infectious Diseases clinic, NCKUH.
Methods
From January 12, 2002 to April 30, 2002. Seventy HIV-infected patients were consulted. We estimated adherence by pill count and self-report form. The interventions contain medication information (organized medication administration schedules, how to take the drug, possible adverse effects, possible drug-drug interaction or drug-food interaction), drug boxes, appointment, education and counseling on HAART.
Results
We found 82% of patients reported >95% adherence. However, only 34.3% of patients followed the dosing schedule. Incorrect medication use in dosing frequency or pill numbers were found in 17.1% of patients. The most common reasons for nonadherence were that they forgot or were busy. As for the relevant knowledge of HIV disease and HAART, the majority of patients did not understand the drug interactions and the goal of HAART. There were 30.9% of patients had no idea about the transmission routes of HIV.
The pharmacist-led intervention significantly increase numbers of patients that followed prescribing order (P <0.001) and decrease numbers of patients skipped taking pills (P = 0.008) and improve patients’ knowledge of HIV disease and HAART (P = 0.024).
Conclusion
With the knowledge of the causes of nonadherence, it is vital to educate and offer supportive counseling, preferably before the initiation of HAART. “Start when the patient is ready” is the first consideration when patients’ disease progression is not emergent. Pharmacists play an important role in the outpatient care of HIV-infected patients by providing pharmaceutical care to ensure the patient adherence to complex treatment regimens.
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