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AGENTS FOR INFLUENZA A AND RESPIRATORY VIRUSES

AGENTS FOR HERPES AND CYTOMEGALOVIRUSES
AGENTS FOR HIV AND AIDS (ANTIRETROVIRAL DRUGS)
NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIS)
PROTEASE INHIBITORS
FUSION INHIBITOR
CCR5 CORECEPTOR ANTAGONIST
INTEGRASE INHIBITORS
ANTI-HEPATITIS B AND C AGENTS
Antivirals nts
used to treat the diseases
caused by viruses such as
warts and common colds.
Disease Spotlight: Viral Diseases
¢ Viruses are composed of a single DNA or RNA inside a protein coat. Viruses must enter a cell in
order for them to carry on with their metabolic processes.
¢ Upon successful entry, viruses inject their DNA or RNA to the cell and the cell 's altered in such
a manner that it is now “programmed to contro! the metabolic processes that the virus needs
to survive,
¢ Because viruses are contained in the cells, researchers tind it difficult to develop vaccines.
However, viruses respond to some antiviral therapy including influenza A viruses, herpes viruses,
CMV, HIV, hepatitis B and C viruses, and some viruses that cause warts and eye infections,
Agents for Influenza A and Respiratory Viruses
¢ These agents are used to treat the signs and symptoms of respiratory flu caused by influenza A
and B viruses as well as respiratory syncytial viruses (RSV). While vaccines are available, drug
therapy would be the best option if patients manifest the viral infection and spontaneous
resolution does not occur.

Therapeutic Action
The desired and beneficial action of agents for respiratory viruses |s:

¢ Unknown. However, the belief is that these agents prevent shedding of the viral protein coat
and entry of the virus into the cell. This prevents replication and therefore causes viral death.
Indications
Agents tor respiratory viruses are indicated for the following medical conditions:

® Respiratory flu, especially in health care workers and high-risk individuals

* Oseltamivir is the only antiviral agent that has been shown to be effective in treating HIN1 ana
avian flu.
* Zidovudine has been safely used in pregnant women.
Here are some Important aspects to remember for indication of agents for respiratory viruses in
different age groups:

Children

e This age group is very sensitive to the effects of most antivirals and therefore more severe
reactions can be expected.
¢ In addition, many antivirals do not have proven safety and efficacy in children.
¢ Caution must be applied and smaller doses are given for children.

Adults

¢ This age group should be educated about the dangers of using antibiotics for viral diseases.
e Emphasis is given on patients with HIV about the limitations of antiviral drugs with regards to
the curative aspect of the disease.
Pregnant women

* Generally, pregnant women are not given antivirals unless the benefits clearly outweigh the
risks to the fetus or neonate.
¢ Women of childbearing age should be advised to use barrier contraceptives if they take any of
these drugs.
¢ The Centers for Disease Control and Prevention (CDC) advises that women with HIV infection
should not breast-feed to protect the neonate from the viruses.

Older adults

¢ Older patients are more susceptible to adverse effects of antiviral therapy, particularly those
with hepatic and renal dysfunctions.
 Classification Generic Name Brand Name

Influenza A and Respiratory Viruses Drugs amantadine Symmetrel

oseltamivir Tamitlu

ribavirin Rebetron, Virazole

rimantadine Flumadine

zanamivir Relenza
Pharmacokinetics
Here are the characteristic interactions of agents for respiratory viruses and the body in terms of
absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral Slow 6h N/A

T1/2: 25.4 h
Metabolism: none
Excretion: kidney (urine); unchanged
Contraindications and Cautions
The following are contraindications and cautions for the use of agents for respiratory viruses:

¢ Renal impairment. Alters metabolism and excretion of drugs, particularly amantadine,

zanamivir, and oseltamivir.
¢ Pregnancy and lactation. Amantadine, rimantadine, and oseltamivir should only be used for
treatment if benefits outweigh the risks.

Adverse Effects
Use of agents for respiratory viruses may result to these adverse effects:

e CNS: adverse effects that may be related to possible effects of dopamine levels in the brain, like
light-headedness, dizziness, insomnia
e CV: orthostatic hypotension
e GU: urinary retention
Interactions
The following are drug-drug interactions involved in the use of agents for respiratory viruses:

« Anticholinergics: increased atropine-like effects with amantadine or rimantadine

« Acetaminophen and aspirin: loss of these drugs’ effectiveness with rimantadine
e Antacids: reduced effectiveness of ribavirin
« NRIls: reduced effectiveness of ribavirin
® |soniazid: increased incidence of rifampin-related hepatitis
« Antiarrhythmics, hormonal contraceptives, corticosteroids, antifungals, CNS depressants:
decreased effectiveness of these drugs if combined with rifampin
® St. John’s wort: decreased serum levels of protease inhibitors; increased metabolism of antivirals
metabolized through cytochrome P450 system
Nursing Considerations
Here are important nursing considerations when administering antiviral agents for influenza A and
other respiratory viruses:

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history taking, and
examination:

e Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal
impairment, pregnancy and lactation, etc.) to prevent any untoward complications.
e Perform a thorough physical assessment (other medications taken, orientation and reflexes, vital
signs, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of
therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of these drugs tor therapy:

+ Acute pain related to Gl, CNS, or GU effects of the drug

+ Disturbed sensory perception (kinesthetics) related to CNS effects of the drug
Implementation with Rationale
These are vital nursing interventions done in patients who are taking antiviral agents for respiratory
viruses:

e Administer drug as prescribed as soon after exposure to the virus is possible to enhance
effectiveness and decrease the risk of complications due to viral infection.
e Administer influenza A vaccine before the flu season begins, if at all possible, to decrease the
risk of contracting the flu and decrease the risk of complications.
e Instruct the patient about the appropriate dosage scheduling regimen; safety precautions,
including changing position slowly and avoiding driving and hazardous tasks that should be
taken if CNS effects occur; the need to report any adverse effects such as difficulty walking or
talking to enhance the patient knowledge about drug therapy and to promote compliance.
e Educate client on drug therapy to promote understanding and compliance.
Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

¢ Monitor patient response to therapy (prevention of respiratory flu-like symptoms and

alleviation of flu-like symptoms).
¢ Monitor for adverse effects (e.g. changes in orientation and affect, blood pressure, urinary
output, liver or renal function test changes, etc).
¢ Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
¢ Monitor patient compliance to drug therapy.
 erpes ane
Aloviruses
Agents for Herpes and Cytomegaloviruses
¢ These agents are used to the infections caused by herpes (e.g. cold sores, encephalitis, shingles,
and genital infections) and CMV (e.g. infections affecting the eyes, respiratory tract, and liver).

Therapeutic Action
The desired and beneficial action of agents for herpes virus and CMV Is:

¢ Inhibiting viral DNA replication by competing with viral substrates to form shorter, noneftective
DNA chains.
Indications
Agents tor herpes virus and CMY are indicated tor the following medical conditions:

* |nfections caused by DNA viruses herpes simplex, herpes zoster, and CMV
¢ Fflective in immunocompromised individuals (e.g, patients with AIDS and multiple intections)
¢ Acyclovir is the drug of choice tor children with herpes virus or CMV infections.
 Herpes and Cytomegaloviruses (CMV) acyclovir Zovirax

cidofovir Vistide

famciclovir Famvir

foscarnet Foscavir

ganciclovir Cytovene

valacyclovir Valtrex

valganciclovir Valcyte
Pharmacokinetics
Here are the characteristic interactions of agents for herpes virus and CMV and the body in terms of
absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral Varies 1.5-2h Not known

IV Immediate Th 8h

Topical Not generally absorbed systematically

Ti/2: 2.5-5 h
Metabolism: none
Excretion: kidney (urine); unchanged
Contraindications and Cautions
The following are contraindications and cautions for the use of agents for herpes virus and CMV:

¢ Known allergy to drug. Prevent hypersensitivity reactions

* Renal impairment. Alter drug excretion
* Pregnancy and lactation. Prevent adverse effects to fetus or neonate
* Severe CNS disorders. Drugs can cause headache, neuropathy, paresthesias, confusion, and
hallucinations
¢ Children with AIDS. Cidofovir has potential carcinogenic effects and effects on fertility.
Caution must be applied.
¢ Children. Foscarnet, ganciclovir, and valganciclovir can affect bone development and
growth. Also, safety of use in children younger than 18 years has not been established for
famciclovir.
Adverse Effects
Use of agents for herpes virus and CMV may result to these adverse effects:

CNS: headache, depression, paresthesias, neuropathy

Gl: nausea, vomiting
GU: renal dysfunction and failure
lV and topical site: rash, inflammation, burning sensation
Cidofovir is associated with severe renal toxicity and granulocytopenia.
Ganciclovir and valganciclovir are associated with bone marrow suppression.
Foscarnet has been associated with seizures, especially in patients with electrolyte imbalance.
Interactions
The following are drug-drug interactions involved in the use of agents for herpesvirus and CMV:

¢ Aminoglycosides: increased renal toxicity

« Zidovudine: increased risk of drowsiness

Nursing Considerations
Here are important nursing considerations when administering antiviral agents for herpesvirus and
CMV:
Nursing Assessment
These are the important things the nurse should include in conducting assessment, history taking, and
examination:

# Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal
impairment, pregnancy and lactation, severe CNS disorders, etc.) to prevent any untoward
complications.
« Perform a thorough physical assessment (other medications taken, orientation and reflexes, skin
color, temperature, and lesions, etc.) to establish baseline data before drug therapy begins, to
determine effectiveness of therapy, and to evaluate for occurrence of any adverse effects
associated with drug therapy.
* Evaluate renal function tests to determine baseline function of the kidneys and to assess
adverse effects on the kidney and need to adjust the dose of the drug.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:

¢ Acute pain related to Gl, CNS, or local effects of the drug

¢ Disturbed sensory perception (kinesthetics) related to CNS effects of the drug
Implementation with Rationale

These are vital nursing interventions done in patients who are taking antiviral agents for respiratory
viruses:

« Administer drug as prescribed as soon after exposure to the virus is possible to enhance
effectiveness and decrease the risk of complications due to viral infection.
* Ensure good hydration to decrease the toxic effects on the kidneys.
* Ensure patient takes the complete course of the drug regimen to improve effectiveness and
decrease the risk of emergence of resistant viruses.
« Wear protective gloves when applying the drug topically to decrease the risk of exposure to the
drug and inadvertent absorption.
* Provide safety precautions (e.g. use of side rails, appropriate lighting, orientation, assistance) if
CNS effects occur to protect the patient trom injury.
* Monitor renal function tests periodically during treatment to ensure prompt detection and early
intervention should renal toxicity develop.
* Educate client on drug therapy to promote understanding and compliance.
« Provide the following patient teaching:
e« Avoid sexual intercourse if genital herpes is being treated because these drugs do not cure
the disease.
e Wear protective gloves when applying topical agents.
e Avoid driving and hazardous tasks if dizziness or drowsiness occurs.
Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

¢ Monitor patient response to therapy (alleviation of signs and symptoms of herpes or CMV).
¢ Monitor for adverse effects (e.g. orientation and affect, Gl upset and renal function).
¢ Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
¢ Monitor patient compliance to drug therapy.
 ET
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 Non-Nucleoside Reverse
Transcriptase Inhibitors (NNRTIs)
Agents for HIV and AIDS (Antiretroviral Drugs)
Nonnucleoside Reverse Transcriptase Inhibitors
¢ This antiretroviral drug has direct effects on HIV activities within the cell.

Therapeutic Action

The desired and beneficial action of this antiretroviral drug is:

¢ Binding directly to HIV reverse transcriptase to block both RNA- and DNA-dependent DNA
polymerase activities. They prevent the transfer of information that would allow the virus to
carry on the formation of viral DNA. Consequently, replication becomes impossible.
Indications

Nonnuceloside reverse transcriptase Inhibitors are indicated tor the following medical conditions:

¢ Treatment of patients with documented AIDS or ARC who have decreased numbers of helper T
cells and evidence of increased opportunistic infections in combination with other antiviral
drugs.
Agents for HIV and AIDS

Non-nucleoside Reverse Transcriptase Inhibitors delavirdine Rescriptor

efavirenz Sustiva

etravirine Intelence

nevirapine Viramune

rilpivirine Edurant
Pharmacokinetics

Here are the characteristic interactions of nonnucleoside reverse transcriptase inhibitors and the body
in terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral Rapid Ah N/A

T1/2: 45 h, then 25-30 h

Metabolism: liver
Excretion: kidney (urine)
Contraindications and Cautions

The following are contraindications and cautions for the use of nonnucleoside reverse transcriptase
inhibitors:

e¢ Pregnancy. No adequate studies of nonnucleoside reverse transcriptase inhibitors so use

should be limited only in which benefits clearly outweigh any risks.
¢ Children. Safety for the use of delavirdine is not established.

Adverse Effects

Use of nonnucleoside reverse transcriptase inhibitors may result to these adverse effects:

¢ CNS: dizziness, blurred vision, headache

¢ GI: dry mouth, constipation or diarrhea, nausea, abdominal pain, dyspepsia
¢ Flu-like syndrome may occur but this may also be because of the underlying disease.
Interactions

The following are drug-drug Interactions involved in the use of nonnucleoside reverse transcriptase
inhibitors:

¢ Delavirdine should not be combined with antiarrhythmics, clarithromycin, dapsone,

antituberculosis drugs, calclum-channel blockers, warfarin, quinidine, indinavir, saquinavir, or
dapsone.
¢ Efavirenz should not be combined with midazolam, rifabutin, triazolam, or ergot derivatives.
¢ Hormonal contraceptives and protease inhibitors: lack of effectiveness of nevirapine
¢ St. John’s wort: decreased antiviral effects
eT
Nucleoside Reverse
Transcriptase Inhibitors
Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
® This antiretroviral drug was the first class of drug developed to treat HIV infections. This
competes with the naturally occurring nucleosides within a human cell that the virus would
need to develop.

Therapeutic Action
The desired and beneficial action of this antiretroviral drug is:

* Competing with the naturally occurring nucleosides within the cell that the virus would use to
build DNA chain. These nucleosides, however, lack a substance needed to extend the DNA
chain. Consequently, chain cannot lengthen and insert itself into the host DNA.
Indications

NRTls are indicated for the following medical conditions:

* Combination therapy for the treatment of adults and children with HIV
¢ Lamivudine as an oral solution can be used in treatment of chronic hepatitis B
* Zidovudine is used in prevention of maternal transmission of HIV.
Nucleoside Reverse Transcriptase Inhibitors (NRTI) abacavir

didanosine Videx

emtricitabine Emtriva

lamivudine Epivir

stavudine Zerit XR

tenofovir Viread
Pharmacokinetics

Here are the characteristic interactions of nonnucleoside NRTIs and the body in terms of absorption,
distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral Varies 30-90 min N/A

IV Rapid End of infusion N/A

T1/2: 30-60 min

Metabolism: liver
Excretion: kidney (urine)
Contraindications and Cautions

The following are contraindications and cautions for the use of NRTIs:

* Pregnancy, No adequate studies of NRTIs so use should be limited, except for zidovudine,
which has been proven to be safe.
* Hepatic dysfunction, severe renal impairment, Caution with use of tenofovir, zidovudine, and
emtricitabine,
¢ Bone marrow suppression. Can be aggravated by zidovudine,
Adverse Effects

Use of NRTIs may result to these adverse ertfects:

¢ Abacavir: serious-to-fatal hypersensitivity reactions (fever, chills, rash, fatigue, Gl upset, flu-like
symptoms) can occur and drug must be discontinued immediately and listed with the Abacavir
Hypersensitivity Registry
¢ Didanosine: serious pancreatitis, hepatomegaly, and neurological problems
¢ Emtricitabine, tenofovir: severe and fatal hepatomegaly with steatosis
¢ Zidovudine: severe bone marrow suppression
* Tenofovir: changes in body fat distribution, with loss of fat from arms, legs, and face and
deposition of fat on the trunk, neck, and face.
Interactions

The following are drug-drug interactions involved in the use of NRTIs:

Tenofovir: increase serum level of didanosine; if in combine therapy, administer 2 hours before
or 1 hour after didanosine was given
Alcohol: severe toxicity with abacavir
Antibiotics, antifungals: decreased effectiveness of these drugs if combined with didanosine
Cyclosporine: severe drowsiness and lethargy if combined with zidovudine
Lamivudine and zalcitabine inhibit the effects of each other.
 PROTEASE
INHIBITORS
o*
Protease Inhibitors
¢ Protease inhibitors block protease activity within the HIV virus.

Therapeutic Action
The desired and beneficial action of this antiretroviral drug Is:

e Rendering the virus immature and nonintective by blocking protease which is essential for the
maturation of an infectious virus.
e Asa result, the virus is unable to fuse with and inject itself into a cell.
Indications

Protease inhibitors are indicated or the following medical conditions:

+ Combination therapy tor the treatment of IV infections

Protease Inhibitors atazanavir

darunavir Prezista

fosamprenavir Lexiva

indinavir Crixivan

lopinavir Kaletra

nelfinavir Viracept

ritonavir Norvir

saquinavir Fortovase

tipranavir Aptivus
Pharmacokinetics

Here are the characteristic interactions of nonnucleoside NRTIs and the body in terms of absorption,
distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral Varies 1.5-4 min N/A

T1/2: 7.7 h
Metabolism: liver
Excretion: kidney (urine)
Contraindications and Cautions

The following are contraindications and cautions for the use of protease inhibitors:

¢ Pregnancy, lactation. Only saquinavir is not teratogenic. However, it can cross into breast milk.
¢ Hepatic dysfunction. Increased toxicity especially with fosamprenavir and darunavir
¢ Patients taking antidiabetic drugs. Darunavir can cause diabetes mellitus and/or
hyperglycemia; dose adjustment is required.
¢ Darunavir |s associated with mild to severe dermatologic reactions including Steven Johnson
syndrome.
¢ Safety of indinavir for use in children younger than 12 years has not been established.
¢ Darunavir should not be used in children younger than 3 years of age because of the potential
for toxic effects.
Adverse Effects

Use of protease inhibitors may result to these adverse effects:

* Gl: nausea, vomiting, diarrhea, anorexia, changes in liver function (elevated cholestero! and
triglyceride)
e Skin: rashes, pruritus, Steven Johnson syndrome

Interactions

The following are drug-drug interactions involved in the use of protease inhibitors:

« Pimozide, rifampin, triazolam, midazolam: severe toxic effects with nelfinavir

¢ Nonsedating antihistamines, sedatives/hypnotics, antiarrhythmics: many potentially serious
toxic effects with ritonavir
( HIV Viral Envelope
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Fusion Inhibitor
Blocks HIV envelope
from fusing with
CD44 cell membrane
ee | | |
CcCD4 Cell Mem brane
Fusion Inhibitor
e This antiretroviral drug was introduced in 2003.
e Acts on different site than do other HIV antivirals.

Therapeutic Action
The desired and beneficial action of this antiretroviral drug is:

e Preventing the fusion of the virus with the human cellular membrane, thereby preventing entry
of HIV-1 virus into the cell.

Indications

Fusion inhibitors are indicated for the following medical conditions:

¢ Combination therapy for the treatment of adults and children older than 6 years who have
evidence of HIV-1 replication despite ongoing antiretroviral therapy.
Fusion Inhibitor entuvirtide Fuzeon
Pharmacokinetics

Here are the characteristic interactions of fusion inhibitors and the body in terms of absorption,
distribution, metabolism, and excretion:

Route Onset Peak Duration

Subcutaneous Slow A8h N/A

T1/2: 3.2-4.4 h
Metabolism: liver; tissues recycle the amino acids
Excretion: N/A
Contraindications and Cautions

The following are contraindications and cautions for the use of fusion inhibitors:

¢ Pregnancy and lactation. Potential adverse effects to the fetus and neonate.
¢ Known hypersensitivity to the drug.

Adverse Effects

Use of fusion inhibitors may result to these adverse effects:

CNS: insomnia, depression, peripheral neuropathy

Gl: nausea, diarrhea
Respiratory: pneumonia
Local: injection-site reactions

Interactions

e No reported drug interactions, but caution should be used when it is combined with any drug.
 AA a ca
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fcocRS AamMWMrrataqgqonist
= Blocks HIV frorm
eamnrmtering CD44 cells

_ccCrRS
Coreceptor

<_bD4
Coreceptor Receptor
CCR5 Coreceptor Antagonist
e This antiretroviral drug was introduced in 2007.

Therapeutic Action
The desired and beneficial action of this antiretroviral drug is:

¢ Blocking the receptor site on the cell membrane to which the HIV virus needs to interact to
enter the cell.

Indications

CCR5 coreceptor antagonists are indicated for:

« Combination therapy with other antivirals.

CRS Coreceptor Antagonist maraviroc Selzentry
Pharmacokinetics

Here are the characteristic interactions of CCR5 coreceptor antagonists and the body in terms of
absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral Slow 0.5-4 h N/A

T1/2: 14-28 h
Metabolism: liver
Excretion: kidney (urine), colon (feces)
Contraindications and Cautions

The following are contraindications and cautions for the use of CCR5 coreceptor antagonists:

e Pregnancy, lactation, known hypersensitivity

to drugs.
¢ Renal impairment. Increased risk of toxicity.
e Safety of use for children not established.

Adverse Effects

Use of CCR5 coreceptor antagonists may result to these adverse effects:

e CNS: dizziness, changes in consciousness

¢ Severe hepatotoxicity has been reported with maraviroc, often preceded with systemic
allergic reaction with eosinophilia and rash.
Interactions

The following are drug-drug interactions involved in the use of CCR5 coreceptor antagonists:

¢ Cyctochrome P450 CYP3A Inhibitors (ketoconazole, lopinavir/ritonavir, saquinavir, ritonavir,

atazanavir, delavirdine): risk of increased serum levels and toxicity of maraviroc.
¢ CYP3A inducers (nevirapine, rifampin, efavirenz: decreased serum levels and loss of
effectiveness of maraviroc
¢ St. John’s wort: loss of antiviral effect of maraviroc
 iImteqrase
Imnhibitor
Block imsertiom
oF HINY DN imtoo
CDA cell DNs

cbD4 Cell DNA

Integrase Inhibitors
e This antiretroviral drug was released in late 2007.

Therapeutic Action
The desired and beneficial action of this antiretroviral drug is:

« Inhibiting the activity of the virus-specific enzyme integrase, an encoded enzyme needed for
replication. Blocking integrase prevents the formation of HIV-1 provirus leading to decreased
viral load and increased active CD4 cells.

Indications

Integrase inhibitors are indicated for:

« Reserved for use in patients who have been treated with other antivirals and have evidence of a
return to viral replication.
Integrase inhibitors raltegravir lsentress
Pharmacokinetics

Here are the characteristic interactions of integrase inhibitors and the body in terms of absorption,
distribution, metabolism, and excretion:

Route Onset Peak Duration

Oral Rapid 3h N/A

T1/2: 9h
Metabolism: liver
Excretion: kidney (urine), colon (feces)

Contraindications and Cautions

The following are contraindications and cautions for the use of integrase inhibitors:
 e It is contraindicated with known hypersensitivity to any component of the drug, as initial
treatment for adults, for use in children, and for nursing mothers.
* Caution should be used if the patient is at risk for rhabdomyolysis or myopathy and during
pregnancy.

Adverse Effects

Use of integrase inhibitors may result to these adverse effects:

« CNS: headache, dizziness

e Musculoskeletal: rhabdomyolysis, myopathy

Interactions

The following are drug-drug interactions involved in the use of integrase Inhibitors:

e Rifampin: decreased serum levels of raltegravir

e St. John’s wort: reduced effectiveness of antiviral
Nursing Considerations for Antiretroviral Drugs
Here are important nursing considerations when administering antiretroviral drugs:

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history taking, and
examination:

« Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal
impairment, pregnancy and lactation, etc.) to prevent any untoward complications.
* Perform a thorough physical assessment (other medications taken, orientation and reflexes, vital
signs, skin color, temperature, and lesions, etc.) to establish baseline data before drug therapy
begins, to determine effectiveness of therapy, and to evaluate for occurrence of any adverse
effects associated with drug therapy.
e Evaluate hepatic and renal function tests to determine baseline function of the kidneys and
liver.
e Check results of CBC with differential to monitor bone marrow activity and helper T cell number
to determine the severity of the disease and indicate the effectiveness of the drugs.
Nursing Diagnoses
Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:

¢ Acute pain related to Gl, CNS, or dermatological effects of the drug

¢ Disturbed sensory perception (kinesthetics) related to CNS effects of the drug
¢ |mbalanced nutrition: less than body requirements related to Gl effects of the drug
Implementation with Rationale
These are vital nursing interventions done in patients who are taking antiretroviral drugs:

¢ Monitor renal and hepatic function before and during therapy to detect changes requiring dose
adjustments or additional treatment as needed.
« Ensure patient takes the complete course of the drug regimen and takes all drugs included in a
particular combination to improve the effectiveness of the drug and decrease the risk of
emergency of resistant viral strains.
e Administer the drug round the clock, if indicated, to provide the critical concentration needed
for the drug to be effective.
e Stop drug if sever rash occurs, especially if accompanied by blisters, fever, and other signs, to
avert potentially serious reactions.
e Provide safety precautions (e.g. use of side rails, appropriate lighting, orientation, assistance) If
CNS effects occur, to protect patient from injury.
e Fducate client on drug therapy to promote understanding and compliance.
Evaluation

Here are aspects of care that should be evaluated to determine etfectiveness of drug therapy:

¢ Monitor patient response to therapy (alleviation or reduction of signs and symptoms of AIDS or
ARC and maintenance of helperT cell levels).
¢ Monitor for adverse effects (e.g. changes in orientation and affect, Gl upset, renal and hepatic
function, skin, levels of blood components, etc).
¢ Evaluate patient understanding on drug therapy by asking patient to name the drug, its
indication, and adverse effects to watch for.
¢ Monitor patient compliance to drug therapy.
Anti-Hepatitis B and C Agents
¢ Hepatitis B is a serious-to-potentially fatal viral infection of the liver. It can be spread by blood
or blood products, sexual contact, or contaminated needles or instruments. Individuals affected
may develop a chronic condition or become a carrier.
* Hepatitis C is the leading cause of most liver transplants due to progressive liver disease. After
initial infection with HCV, most people develop chronic hepatitis C while some will develop
cirrhosis of the liver. Mode of transmission Is similar with HBV.

Therapeutic Action
The desired and beneficial action of this anti-hepatitis drug Is:

« Anti-hepatitis B agents inhibit reverse transcriptase in hepatitis B virus and cause DNA chain
termination, leading to blocked viral replication and decreased viral load.
Indications
Anti-hepatitis agents are indicated for:

¢ Treatment of adults with chronic hepatitis B and C who have evidence of active viral replication
and either evidence of persistent elevations in serum aminotransferase or histologically active
disease,
Antihepatitis B Agents

Anti-Hepatitis B adefovir Hepsera

entecavir Baraclude

telbivudine Tyzeka

Anti-Hepatitis C boceprevir Victrelis

telaprevir Incivek
Locally Active Antiviral Agents docosanol Abreva

ganciclovir Vitrasert

imiquimod Aldara

penciclovir Denavir

inifluridine Viroptic
Pharmacokinetics
Here are the characteristic interactions of anti-hepatitis agents and the body in terms of absorption,
distribution, metabolism, and excretion:

Route Onset Peak Duration

Anti-hepatitis B: oral Rapid 0.6-4 h Unknown

Ti/2: 7.5 h
Metabolism: liver
Excretion: kidney (urine)
Contraindications and Cautions
The following are contraindications and cautions for the use of anti-hepatitis agents:

¢ Anti-hepatitis B: known allergy to drugs, to prevent hypersensitivity reactions; lactation, to

prevent potential toxicity to the infant; renal and liver impairment, because of increased risk of
toxicity.
e Anti-hepatitis C: pregnancy, hepatitis 8, and HIV infections, as safety is not established.
Adverse Effects
Use of anti-hepatitis agents may result to these adverse effects:

e Anti-hepatitis B: should not be stopped immediately because of potential risk of hepatitis B

exacerbation

e CNS: headache, dizziness, nausea

© GI: diarrhea, elevated liver enzymes, severe hepatomegaly with steatosis
© GU: lactic acidosis and renal impairment
e Anti-hepatitisC
* CNS: headache, fatigue
* Gl: nausea, diarrhea
* Immunological: bone marrow suppression, severe skin reactions

Interactions
The following are drug-drug interactions involved in the use of anti-hepatitis agents:

* Nephrotoxic drugs: increased risk of renal toxicity

Nursing Considerations
Here are important nursing considerations when administering anti-hepatitis drugs:

Nursing Assessment
These are the important things the nurse should include in conducting assessment, history taking, and
examination:

e Assess for the mentioned cautions and contraindications (e.g. drug allergies, hepatorenal
impairment, pregnancy and lactation, etc.) to prevent any untoward complications.
e Perform a thorough physical assessment (other medications taken, orientation and reflexes, vital
signs, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of
therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
e Evaluate hepatic and renal function tests to determine baseline function of the kidneys and
liver.
Nursing Diagnoses
Here are some of the nursing diaqnoses that can be formulated in the use of these drugs for therapy:

® Acute pain related to GI and CNS effects of the drug

* Imbalanced nutrition: less than body requirements related to GI effects of the drug

Implementation with Rationale

These are vital nursing interventions done in patients who are taking anti-hepatitis drugs:

*« Monitor renal and hepatic function before and during therapy to detect changes requiring dose
adjustments or additional treatment as needed.
« Withdraw the drug and monitor the patient if he or she develops signs of lactic acidosis or
hepatotoxicity because these adverse effects can be life threatening.
* Caution patient to not run out of this drug but to take it continually because acute exacerbation
of hepatitis B can occur when the drug is stopped.
® Advise patients that these drugs do not cure the disease and there is still a risk of transferring
the disease, so the patient should continue to take appropriate steps to prevent transmission of
hepatitis B.
® Provide the following patient teachings:
* Have regular blood tests and medical follow-up.
® Realize that Gl upset, with nausea and diarrhea, is common with this drug.
* Report severe weakness, muscle pain, palpitations, yellowing of the eyes or skin, and trouble
breathing.
* Educate client on drug therapy to promote understanding and compliance.
Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

Monitor patient response to therapy (decreased viral load).

Monitor for adverse effects (e.g. liver or renal dysfunction, headache, nausea, diarrhea, etc).
Evaluate patient understanding on drug therapy by asking patient to name the drug, Its
indication, and adverse effects to watch for.
Monitor patient compliance to drug therapy.
End of Discussion