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

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.

• Reassure the patient that these adverse effects generally improve over time (usually in 6–8 weeks).
• Consider switching to ARV drugs with smaller tablet sizes (see Appendix A,Table 2. Antiretroviral Fixed-Dose Combination Tablets: Minimum Body Weights and Considerations for Use in Children and Adolescents).
• Provide supportive care.
• In extreme or persistent cases, use antiemetics or switch to another ARV regimen.

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.