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 16, 2019; Last Reviewed: April 16, 2019
|Adverse Effects||Associated ARVs||Onset/Clinical Manifestations||Estimated Frequency||Risk Factors||Prevention/Monitoring||Management|
|Hepatitis||Most ARV drugs have been associated with hepatitis, but there is a strong association between hepatitis, NVP, and EFV.
NVP, EFV, ABC, RAL, DTG, and MVC have been associated with hepatitis in the context of HSRs.
NRTIs have been associated with lactic acidosis and hepatic steatosis, especially ZDV.
||Uncommon||HBV or HCV coinfection
Underlying liver disease
Use of other hepatotoxic medications and supplements (e.g., St. John's wort [Hypericum perforatum], chaparral [Larrea tridentata], germander [Teucrium chamaedrys])
Higher drug concentrations of PIs
For NVP-Associated Hepatic Events in Adults:
For ARV Drugs Other Than NVP:
|Evaluate the patient for other infectious and non-infectious causes of hepatitis and monitor the patient closely.
||In long-term follow-up, 9% of children receiving ATV had at least one total bilirubin level >5 times ULN and 1.4% of children experienced jaundice.||N/A||Monitoring:
||Isolated indirect hyperbilirubinemia is not an indication for cessation of the potentially offending ARV drug.
Psychological impact of jaundice should be evaluated, and alternative agents should be considered.
Jaundice may result in nonadherence, particularly in adolescents; this side effect should be discussed.
|Non-Cirrhotic Portal Hypertension||d4T, ddI
The Panel no longer recommends the use of these agents.
||Rare||Prolonged exposure to ddI and the combination of d4T and ddI.||Monitoring:
||Manage complications of GI bleeding and esophageal varices.|
|a For example, HLA-DRB1*0101 in white people, HLA-DRB1*0102 in South Africans, and HLA-B35 in Thai people and white people.
b Less-frequent monitoring can be considered in children whose clinical status is stable for >2 years to 3 years (see Clinical and Laboratory Monitoring of Pediatric HIV Infection).
Key to Acronyms: 3TC = lamivudine; ABC = abacavir; ALP = alkaline phosphatase; ALT = alanine transaminase; ARV = antiretroviral; AST = aspartate aminotransferase; ATV = atazanavir; CD4 = CD4 T lymphocyte; CMV = cytomegalovirus; COBI = cobicistat; d4T = stavudine; ddI = didanosine; DTG = dolutegravir; EBV = Epstein-Barr virus; EFV = efavirenz; FTC = emtricitabine; GI = gastrointestinal; HAV = hepatitis A virus; HBV = hepatitis B virus; HCV = hepatitis C virus; HLA = human leukocyte antigen; HSR = hypersensitivity reaction; IRIS = immune reconstitution inflammatory syndrome; MVC = maraviroc; NRTI = nucleoside reverse transcriptase inhibitor; NVP = nevirapine; PI = protease inhibitor; RAL = raltegravir; RTV = ritonavir; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; ULN = upper limit of normal; ZDV = zidovudine