Table 15c. Antiretroviral Therapy–Associated Adverse Effects and Management Recommendations—Gastrointestinal Effects

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Table 15c. Antiretroviral Therapy–Associated Adverse Effects and Management Recommendations—Gastrointestinal Effects
Adverse Effects Associated ARVs Onset/Clinical Manifestations Estimated Frequency Risk Factors Prevention/ Monitoring Management

Nausea/‌Vomiting

All ARV drugs, but most notably RTV-boosted PIs

Onset

  • Early

Presentation

  • Nausea and emesis, both of which may be associated with anorexia and/or abdominal pain

Varies by ARV agent; generally <15%

Unknown

  • Instruct patient to take PIs with food.
  • Monitor for weight loss and ARV adherence.

Diarrhea

All ARV drugs, but most notably RTV-boosted PIs

Onset

  • Early

Presentation

  • More frequent bowel movements and stools that are generally soft

Varies by ARV agent; generally <15%

Unknown

Monitor for weight loss and dehydration.

  • In prolonged or severe cases, exclude infectious or noninfectious (e.g., lactose intolerance) causes of diarrhea.
  • Reassure patient that this adverse effect generally improves over time (usually in 6–8 weeks). Consider switching to another ARV regimen in persistent and severe cases.
  • Treatment data in children are lacking; however, the following strategies may be useful when the ARV regimen cannot be changed:
    • Modifying the diet
    • Using bulk-forming agents (e.g., psyllium)
    • Using antimotility agents (e.g., loperamide)
    • Using crofelemer, which is approved by the FDA to treat ART-associated diarrhea in adults aged ≥18 years; no pediatric data are available.

Pancreatitis

Rare, but may occur with NRTIs or RTV-boosted PIs

Onset

  • Any time, usually after months of therapy

Presentation

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

<2%

Use of concomitant medications that are associated with pancreatitis (e.g., TMP-SMX, pentamidine, ribavirin)

Hypertriglyceridemia

Advanced HIV infection

Previous episode of pancreatitis

Alcohol use

Measure serum amylase and lipase concentrations if persistent abdominal pain develops.

  • Discontinue offending agent and avoid reintroduction.
  • Manage symptoms of acute episodes.
  • If pancreatitis is associated with hypertriglyceridemia, consider using interventions to lower TG levels.
Key: ART = antiretroviral therapy; ARV = antiretroviral; FDA = U.S. Food and Drug Administration; NRTI = nucleoside reverse transcriptase inhibitor; PI = protease inhibitor; RTV = ritonavir; TG = triglyceride; TMP-SMX = trimethoprim sulfamethoxazole

 

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