Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection
The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.
Management of Medication Toxicity or Intolerance
Last Updated: April 14, 2020; Last Reviewed: April 14, 2020
|Adverse Effects||Associated ARVs||Onset/Clinical Manifestations||Estimated Frequency||Risk Factors||Prevention/ Monitoring||Management|
|Reported frequency varies with specific ARV regimen, duration of ART, and the specific laboratory parameters used to diagnose lipid abnormalities.
10% to 20% of young children receiving LPV/r will have lipid abnormalities.
40% to 75% of older children and adolescents with prolonged ART history will have lipid abnormalities.
Higher abnormal fasting serum lipids have been observed in ART-naive adults who received EVG/c/FTC/TAF than in those who received EVG/c/FTC/TDF.
Increase in serum lipids from baseline has also been noted in adolescents receiving EVG/c/FTC/TAF.
|Advanced-stage HIV disease
High-fat, high-cholesterol diet
Lack of exercise
Family history of dyslipidemia or premature ASCVD
Adolescents and Adults:
|Assess all patients for additional ASCVD risk factors. Patients with HIV are considered to be at moderate risk of ASCVD.b
ARV regimen changes should be considered, especially when the patient is receiving older PIs (e.g., LPV/r) and/or RTV boosting. Switching to a PI-sparing regimen, a PI-based regimen with a more favorable lipid profile, or COBI boosting causes a decline in LDL-C or TG values. However, the lipid-lowering effect for LDL-C is less pronounced than with statin therapy.
Refer patients to a lipid specialist early if LDL-C is ≥250 mg/dL or TG is ≥500 mg/dL.
If LDL-C is ≥130 mg/dL but <250 mg, or TG is ≥150 mg/dL but <500 mg/dL, the following staged treatment approach is recommended by the NHLBI guidelines:b
a Given the burden of collecting fasting blood samples, some practitioners routinely measure cholesterol and TG from nonfasting blood samples and follow up abnormal values with a test done in the fasted state.
b Refer to the NHLBI guidelines: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents.
Key: ALT = alanine aminotransferase; ART = antiretroviral therapy; ARV = antiretroviral; ASCVD = atherosclerotic cardiovascular disease; AST = aspartate aminotransferase; ATV = atazanavir; CK = creatine kinase; COBI = cobicistat; DRV = darunavir; DRV/r = darunavir/ritonavir; EFV = efavirenz; ETR = etravirine; EVG/c = elvitegravir/cobicistat; FLP = fasting lipid profile; FTC = emtricitabine; HDL-C = high-density lipoprotein cholesterol; INSTI = integrase strand transfer inhibitor; LDL-C = low-density lipoprotein cholesterol; LFT = liver function test; LPV/r = lopinavir/ritonavir; NHLBI = National Heart, Lung, and Blood Institute; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; NVP = nevirapine; PI = protease inhibitor; PUFA = polyunsaturated fatty acid; RPV = rilpivirine; RTV = ritonavir; TAF = tenofovir alafenamide; TC = total cholesterol; TDF = tenofovir disoproxil fumarate; TG = triglycerides