3Learning ObjectivesDescribe how antiviral and antiretroviral medications workList common medications used in treating AIDS and AIDS-related fungal infectionsOutline Standard Precautions the nurse takes in limiting exposure to AIDS
4HIV Infection Acquired immunodeficiency syndrome (AIDS) Viral diseaseHigh mortality rateHigh-risk populations include:Homosexual and bisexual menIntravenous drug usersPeople in prisonFemale sexual partners of people in high-risk groupsChildren born to mothers at riskAIDS 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.
5Antivirals Action and Uses Adverse Reactions Decrease symptoms of viral infectionLessen the symptoms of viral illness in immunocompromised patients or adults and children at riskAdverse ReactionsHepatotoxicity, nephrotoxicity, blood dyscrasias, peripheral neuropathiesViral 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.
6Antivirals (cont.) Nursing Implications and Patient Teaching Medications do not cureFollow specific storage instructionsReporting adverse reactionsAdministrationEncourage immunocompromised clients in areas with impure water supplies to drink bottled water onlyReview 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.)
7Antiretrovirals Action Interfere with the ability of a retrovirus to reproduce or replicateTwo types:Reverse transcriptase inhibitorsAct early in viral life cycleProtease inhibitorsAct later in viral life cycleAntiretrovirals 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.
8Antiretrovirals (cont.) UsesSlow advance of AIDSMaintain immunityPrevention of HIV in infants born to HIV-infected mothersPrevention of HIV in healthcare workers exposed to HIVDrug InteractionsAntiretrovirals 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?
9Antiretrovirals (cont.) Nursing Implications and Patient TeachingAdherence is essentialMedications do not cureReport all drugs and supplements used, including OTC and CAMSigns and symptoms of pancreatitisSigns and symptoms of peripheral neuropathyPatients 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.)
10Antiretrovirals (cont.) Nursing Implications and Patient Teaching(cont.)Routes of disease transmissionNeed for social and financial supportHIV-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.
11Antifungals Action Uses Fungistatic Fungicidal Treat mycotic infectionsFungal-specific medicationsSystemic medicationsFungi 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.
12Antifungals (cont.) Common Antifungal Medications: Ketoconazole (Nizoral)Broad-spectrum fungistatic and fungicidal actionUsed to treat oral thrush, candidiasis, histoplasmosisNystatin (Mycostatin)Antibiotic with fungistatic and fungicidal actionUsed to treat intestinal, vaginal, and oral fungal infections caused by Candida strainsThese 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.
13Antifungals (cont.) Common Antifungal Medications (cont.) Amphotericin B (Amphotec)Systemic drugGriseofulvinActivity decreased with barbituratesMetronidazole (Flagyl)Related drug for mixed fungal and bacterial or protozoa infections; interacts with alcoholAmphotericin 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.
14Antifungals (cont.) Nursing Implications and Patient Teaching Take all the medication as ordered; do not stop when symptoms disappearAvoid alcoholReport nausea, vomiting, and diarrhea; watch for easy bruising, sore throat, rash, or feverNystatin must be shaken thoroughly before useIntolerance to the sun (photosensitivity) can occur with griseofulvin therapyCleanliness of hair, skin and nails will limit spreadIt 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?