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Updated Pediatric ARV Guidelines

Updates to the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection were released on Thursday, November 1, 2012. Please send your comments to ContactUs@aidsinfo.nih.gov by November 15, 2012.

Corrections were made to the guideline. For a description of the changes, please see the correction notice.

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Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection

Management of Medication Toxicity or Intolerance

Gastrointestinal Effects

(Last updated:11/1/2012; last reviewed:11/1/2012)

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Table 17c. Antiretroviral Therapy-Associated Adverse Effects and Management Recommendations—Gastrointestinal Effects
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Adverse Effects Associated ARVs Onset/Clinical Manifestations Estimated Frequency Risk Factors Prevention/ Monitoring Management
Nausea/ Vomiting Principally ZDV and PIs (such as LPV/r, RTV) but can occur with all ARVs Onset:
Early

Presentation:
Nausea, emesis—may be associated with anorexia and/or abdominal pain

 Varies with ARV agent. 10%–30% in some series. Unknown Instruct patient to take PIs with food.

Generally improves with time; monitor for weight loss, ARV adherence.

 Reassure patient/caretaker that nausea and vomiting will likely decrease over time.

Provide supportive care including instruction on dietary modification.

Although antiemetics are not generally indicated, they may be useful in extreme or persistent cases.
Diarrhea PIs (NFV, LPV/r, FPV/r), buffered ddI Onset:
Early

Presentation:
Generally soft, more frequent stools

 Varies with ARV agent.
10%–30% in some series. 		Unknown Generally improves with time (usually over 6-8 weeks); monitor for weight loss, dehydration. Exclude infectious causes of diarrhea.

Although data in children on treatment for ARV-associated diarrhea are lacking, dietary modification, use of calcium carbonate, bulk-forming agents (psyllium), or antimotility agents (loperamide) may be helpful.
Pancreatitis ddI (especially with concurrent d4T or TDF); reported,
albeit rarely, with most ARVs		 Onset:
Any time, usually after months on therapy

Presentation:
Emesis, abdominal pain, elevated amylase and lipase (asymptomatic hyperamylasemia or elevated lipase do not in and of themselves indicate pancreatitis)

 <1%–2% in recent series. Frequency was higher in the past with higher dosing of ddI. Concomitant treatment with other medications associated with pancreatitis (such as TMP-SMX, pentamidine, ribavirin)

Hypertrigly-ceridemia

 Avoid use of ddI in patients with history of pancreatitis. Discontinue offending agent.

Manage symptoms of acute episode.

If associated with hypertrigly-ceridemia, consider interventions to lower TG levels.

Key to Acronyms: ARV = antiretroviral, d4T = stavudine, ddI = didanosine, FPV/r = fosamprenavir/ritonavir, LPV = lopinavir, LPV/r = lopinavir/ritonavir, NFV = nelfinavir, PI = protease inhibitor, RTV = ritonavir, TDF = tenofovir disoproxil fumarate, TG = triglyceride, TMP-SMX = trimethoprim sulfamethoxazole, ZDV = zidovudineavudine

References

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