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 Zambia HIV National Guidelines
 


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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Organ System>
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Nausea/Vomiting

Robin McKenzie, M.D.
08-03-2009

Zambia Specific Information

  • Causes in Zambia expected to be same as those below plus malaria.  
  • With patients on d4T or AZT, lactic acid testing is important (if available) since lactic acidosis can be life-threatening.
  • Available anti-emetic medicines in Zambia are limited; metoclopramideand promethazine most widely used.
Zambia Information Author: David Riedel, M.D.

CLINICAL

  • Often caused by medications: antiretrovirals (esp. RTV, other PIs, AZT), high-dose TMP-SMX, macrolides, opiates.
  • Prevention or treatment of nausea important to improve adherence to therapy.
  • Initiation of ART: nausea greatest in 1st 1-2 wks of ART. Consider prn antiemetic when starting some regimens.
  • Nausea/vomiting may be a sign of a life-threatening reaction to ART: ABC hypersensitivity; NVP hepatotoxicity; lactic acidosis (d4T, ddI, AZT); pancreatitis w/ ddI, especially if combined with d4T (contraindicated), ribavirin (contraindicated) or TDF (reduce dose of ddI).
  • Metabolic causes: adrenal insufficiency, uremia, hypercalcemia
  • CNS disease: mass lesions, meningitis
  • GI disease: gastritis, gastroparesis, reflux esophagitis, PUD, lymphoma, KS, hepatobiliary disease (including drug-induced hepatitis), pancreatitis
  • Misc: opiate withdrawal, pregnancy

DIAGNOSIS

  • Review medications and consider drug-related effects, especially life-threatening conditions (above).
  • Check urine or serum HCG if pregnancy a possibility.
  • Check lactic acid level if taking NRTI, esp. d4T, ddI, AZT.
  • Consider measuring liver enzymes, creatinine, electrolytes, calcium, amylase/lipase.
  • Consider cosyntropin stimulation test (especially with hyperkalemia, wt. loss, eosinophilia, orthostatis/hypotension).
  • Consider GI and/or CNS imaging.

TREATMENT

General principles

  • If pt has life-threatening ART-related side effect, stop ART.
  • If Sx occurs with initiation of ART, remind pt that they may improve within 1-2 wks and consider offering symptomatic treatment.
  • If Sx do not improve significantly or if symptomatic Rx inadequate, consider changing ART.
  • Higher doses of RTV associated with more GI Sx than lower doses. In CASTLE study diarrhea and nausea occurred in 2% and 4% of pts taking ATV/r + TDF/FTC vs. 11% and 8% taking LPV/r twice-daily + TDF/FTC.
  • NRTIs: ddI - take on empty stomach. Others - take w/ or w/o food (may be better tolerated w/ food, especially AZT).
  • NNRTIs: EFV - take on empty stomach initially, to decrease CNS side effects. ETR - take w/ food. NVP - take w/ or w/o food.
  • PIs: IDV - take on empty stomach. ATV, DRV/r, LPV/r solution, NFV, RTV, SQV/r, TPV/r - take w/ food. FPV, IDV/r, LPV/r tabs - take w/ or w/o food (may be better tolerated w/ food).
Symptomatic Therapy

  • Prochlorperazine (Compazine) 5-10 mg PO q6-8h prn, 25 mg PR twice-daily prn, 5-10 mg IM q3-4h prn
  • Promethazine (Phenergan) 12.5-25 mg PO, PR, or IM q4-6h prn
  • Trimethobenzamide (Tigan) 300 mg PO, 200 mg PR, 200 mg IM q6-8h prn
  • Metoclopramide (Reglan) 10 mg PO q6h prn. For ART-associated Sx, consider 10 mg PO 30-60 min before ART.
  • Ondansetron (Zofran) 8 mg PO 3 times-daily
  • Dronabinol (Marinol) 2.5 mg PO twice-daily. If persistent CNS Sx, reduce to 2.5 mg/d. If tolerated, may increase to 10-20 mg/d.
  • Lorazepam (Ativan) 1-3 mg PO q4-6h, max 4 mg/d
  • Note: prochlorperazine, promethazine, trimethobenzamide, and metoclopramide can cause sedation and dystonic/extrapyramidal reactions.
  • Ondansetron and newer 5-HT3 receptor antagonists are expensive. They are used alone or with dexamethasone for chemotherapy-induced nausea and vomiting.
  • Marijuana has appetite-stimulating and antiemetic properties. Medicinal use legal only in CA and AZ.
  • Lorazepam and other benzodiazepines used only for anxiety-associated nausea and vomiting, usually w/ chemotherapy.

Drug Comments

DrugRecommendations/Comments
Benzodiazepines Lorazepam, an anxiolytic, sedating medication, sometimes given PO or IV for anxiety-related nausea, such as that induced by chemotherapy.
dronabinol Active ingredient of marijuana. Approved for treatment of nausea and vomiting associated with chemotherapy and anorexia in pts with AIDS. Decreases nausea and improves appetite but has little effect on weight. Low doses stimulate appetite, but higher doses sometimes necessary for nausea. Side effects (euphoria, emotional lability, dizziness, confusion) preclude its use in some pts.
Ondansetron A serotonin receptor blocker given PO or IV for severe chemotherapy-induced nausea. Expensive. Limited experience in HIV+ pts. (See Gompels M, McWilliams S, O'Hare M, et al. ref)

REFERENCES

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