1. Antivirals, Antiretrovirals and Antifungal Medications
Chapter 13
Antivirals, Antiretrovirals and Antifungal Medications

2. Chapter 13
Lesson 13.1

3. Learning Objectives
Describe how antiviral and antiretroviral medications work
List common medications used in treating AIDS and AIDS-related fungal infections
Outline Standard Precautions the nurse takes in limiting exposure to AIDS

4. HIV Infection Acquired immunodeficiency syndrome (AIDS)
Viral disease
High mortality rate
High-risk populations include:
Homosexual and bisexual men
Intravenous drug users
People in prison
Female sexual partners of people in high-risk groups
Children born to mothers at risk
AIDS is caused by a retrovirus (currently named human immunodeficiency virus, or HIV). Retroviruses are viruses that contain ribonucleic acid (RNA) rather than deoxyribonucleic acid (RNA) as their genetic material.
More than 98% of patients with the severest form of AIDS die within 5 years of diagnosis. However, advances in treatment have significantly prolonged patient lifespan.
AIDS probably arose in central Africa in the 1950s. Today, AIDS is a disease that affects the world in epidemic proportions.

5. Antivirals Action and Uses Adverse Reactions
Decrease symptoms of viral infection
Lessen the symptoms of viral illness in immunocompromised patients or adults and children at risk
Adverse Reactions
Hepatotoxicity, nephrotoxicity, blood dyscrasias, peripheral neuropathies
Viral infections are not suppressed by antibiotics. Studies of viruses such as HIV, herpes, and cytomegalovirus have led to the development of a variety of antiviral drugs.
All these medications are associated with risk, and the benefit-to-risk ratio must be evaluated before their use.
These medications interact with many different products, including some not typically involved in drug reactions.

6. Antivirals (cont.) Nursing Implications and Patient Teaching
Medications do not cure
Follow specific storage instructions
Reporting adverse reactions
Administration
Encourage immunocompromised clients in areas with impure water supplies to drink bottled water only
Review the Nursing Process (ADPIE) as it applies to patients receiving antiviral medications.
Patient teaching is always an essential component of any medication regimen.
Patients and significant family members must be taught not only the action and uses of specific medication but also how to store and administer the product.
Why is bottled water recommended for immunocompromised patients? (Because they are at greater risk for further infections. Using bottled water, if it is available, avoids potential pathogens in untreated or poorly treated water supplies.)

7. Antiretrovirals Action
Interfere with the ability of a retrovirus to reproduce or replicate
Two types:
Reverse transcriptase inhibitors
Act early in viral life cycle
Protease inhibitors
Act later in viral life cycle
Antiretrovirals are an important group of drugs that slow the growth or prevent the duplication of retroviruses. They are used to limit the advance of HIV and AIDS.
Reverse transcriptase inhibitors prevent the HIV enzyme reverse transcriptase from creating HIV proviral DNA from the viral RNA. This in turn prevents more viruses from being produced. There are two categories of reverse transcriptase inhibitors: nucleoside analogue reverse transcriptase inhibitors and nonnucleoside analogue reverse transcriptase inhibitors.
Protease inhibitors result in noninfectious HIV virions being produced.

8. Antiretrovirals (cont.)
Uses
Slow advance of AIDS
Maintain immunity
Prevention of HIV in infants born to HIV-infected mothers
Prevention of HIV in healthcare workers exposed to HIV
Drug Interactions
Antiretrovirals are relatively new drugs and can cause severe toxic reactions: pancreatitis, peripheral neuropathy, myopathy, and less serious conditions such as mouth ulcers, rash, headaches, diarrhea, and nausea.
Why should antiretrovirals not be taken with other drugs? (They inhibit the cytochrome P-450 enzyme system in the liver, which enables the liver to metabolize medications.)
Most of the drugs used in the treatment of AIDS are toxic to the liver. Past or present history of hepatitis or hepatomegaly (enlarged liver), pancreatitis, and alcohol use or abuse could be contraindications to anteretroviral therapy.
What laboratory tests would be done to assess liver and pancreatic function?

9. Antiretrovirals (cont.)
Nursing Implications and Patient Teaching
Adherence is essential
Medications do not cure
Report all drugs and supplements used, including OTC and CAM
Signs and symptoms of pancreatitis
Signs and symptoms of peripheral neuropathy
Patients must be closely supervised and assessed when taking these medications. What lab tests should be done before starting these medications? During?
Encourage the client to inform his or her health care provider about ALL other medications and supplements being taken.
Signs and symptoms of pancreatitis include sudden and severe abdominal pain, nausea, fever, and leukocytosis.
If signs and symptoms of peripheral neuropathy are noted in a patient taking antiretrovirals, what is the most appropriate nursing intervention? (Alert the prescribing physician. Peripheral neuropathy is usually reversible when the medication is discontinued early.)

10. Antiretrovirals (cont.)
Nursing Implications and Patient Teaching
(cont.)
Routes of disease transmission
Need for social and financial support
HIV-positive patients and their families must be counseled regarding disease-transmission routes. All HIV women should be warned of the high risk of HIV transmission in breast milk. The CDC advises HIV-infected women not to breastfeed.
Psychosocial and financial factors have a significant impact on a client’s ability to adhere to the prescribed medication regime.

11. Antifungals Action Uses Fungistatic Fungicidal
Treat mycotic infections
Fungal-specific medications
Systemic medications
Fungi are plants that produce yeastlike or moldlike diseases called mycotic infections in humans. These can be either superficial infections or systemic infections.
Because fungi are found almost everywhere, they pose a risk for immunocompromised patients, including those taking corticosteroids.
Many opportunistic infections in AIDS patients are fungal in nature.

12. Antifungals (cont.) Common Antifungal Medications:
Ketoconazole (Nizoral)
Broad-spectrum fungistatic and fungicidal action
Used to treat oral thrush, candidiasis, histoplasmosis
Nystatin (Mycostatin)
Antibiotic with fungistatic and fungicidal action
Used to treat intestinal, vaginal, and oral fungal infections caused by Candida strains
These are two of the most common antifungal medications used.
Patients taking ketoconazole should be monitored closely for hepatic toxicity.
Nystatin topical cream is available OTC and is used in the treatment of vaginal Candida infections.

13. Antifungals (cont.) Common Antifungal Medications (cont.)
Amphotericin B (Amphotec)
Systemic drug
Griseofulvin
Activity decreased with barbiturates
Metronidazole (Flagyl)
Related drug for mixed fungal and bacterial or protozoa infections; interacts with alcohol
Amphotericin is a highly toxic drug given IV or PO to aggressively treat fungal infections. This drug is given in increasingly high dosages and is used in patients with progressive and potentially fatal fungal infections.
Griseofulvin is a common antifungal agent that is absorbed over a long period of time. Commonly, a daily dose is all that is required. It should be taken with meals high in fat to enhance absorption of the drug. Griseofulvin activity is decreased when used at the same time as barbiturates, requiring dosage adjustments of griseofulvin.
Patients taking metronidazole (Flagyl) should be counseled not to drink alcohol or ingest alcohol-containing products, because severe GI and cardiovascular responses may develop.

14. Antifungals (cont.) Nursing Implications and Patient Teaching
Take all the medication as ordered; do not stop when symptoms disappear
Avoid alcohol
Report nausea, vomiting, and diarrhea; watch for easy bruising, sore throat, rash, or fever
Nystatin must be shaken thoroughly before use
Intolerance to the sun (photosensitivity) can occur with griseofulvin therapy
Cleanliness of hair, skin and nails will limit spread
It may take several weeks before lab tests show that the infection is gone.
Use of alcohol while taking antifungals potentiates, or increases, the effect of the alcohol.
These medications are extremely toxic to the liver and renal system. Nausea, vomiting and diarrhea are common symptoms of toxicity. In addition, symptoms such as bruising, sore throat or fever should be reported to the physician.
Patient teaching is essential to assist with the effectiveness of the medication. Patients who stop taking these medications prematurely are at risk for superinfection.
Why do you think patients allergic to penicillin may exhibit cross-sensitivity to antifungal agents?