晚期患者的治疗策略.ppt

免疫抑制剂 西罗莫司、他克莫司、环孢素A与依非韦伦合用时浓度下降，与PIs或伏立康唑合用时浓度上升，需要TDM； 来氟米特与奈韦拉平合用时增加肝毒性风险，有报道引起肝功能不全甚至急性肝坏死，需要密切监测。 抗肿瘤药 长春新碱和长春花碱与PIs/r合用时浓度升高，增加神经毒性，建议暂停PIs/r；与伏立康唑合用时建议酌减剂量； 达沙替尼和尼洛替尼与PIs/r合用时需要酌减剂量。 植物成分 葡萄柚能诱导肠道CYP3A4，显著降低PIs/r的浓度，因此使用PIs/r的患者禁忌服用葡萄柚及其提取物。 金丝桃素能降低PIs、NNRTIs、CCR5抑制剂和伏立康唑的浓度，避免合用，其中磷酸安普那韦、洛匹那韦/r、tipranavir禁忌合用。 其他药物 左醋美沙朵：与奈韦拉平合用时血药浓度上升，密切监测心电图； 美沙酮：与PIs合用时浓度可能降低出现戒断综合征，与奈韦拉平及依非韦伦合用时时酌增剂量，与伏立康唑合用时酌减剂量； 芬太尼：与伏立康唑、洛匹那韦/r合用时浓度升高，酌减剂量； 可卡因与伏立康唑合用时浓度上升，剂量减半； 非甾体抗炎药与伏立康唑合用时浓度上升，剂量减半。 结 论 早期ART治疗 病人利益 药物副作用/发生耐药, 因此强烈推荐对于HIV感染应及早诊断. “一个患者也不能掉队” 策略提示: 治疗方案应当个体化: 预防和治疗IRIS 社会经济地位 降低对于HIV的歧视 晚期就诊者=机会性感染治疗+ART 药物相互作用 服用药片数量和次数造成依从性差等问题的周全考虑 * 谢谢您的聆听 * ART, antiretroviral therapy * INITIATE ART REGARDLESS OF CD4 COUNT OR CLINICAL STAGE RECOMMENDATION ADULTS WITH HIV… …and active TB disease Strong, low-quality evidence …and HBV co-infection with severe liver disease Strong, low-quality evidence …who are pregnant or breastfeeding Strong, moderate-quality of evidence …in a HIV serodiscordant partnership Strong, high-quality evidence CHILDREN 5 YEARS OLD WITH HIV Infants diagnosed in the first year of life Strong, moderate-quality of evidence Children infected with HIV between one and below five years of age Conditional, very-low-quality evidence * Slide: Transmitted HIV Antiretroviral Drug Resistance (2007-2010) Kim and colleagues collected HIV-1 nucleotide sequence data from persons newly diagnosed with HIV-1 infection who did not have evidence of prior ARV drug use in 10 HIV surveillance areas in the United States from 2007 to 2010 and reported to CDC through June 2011.1 CDC HIV-1 mutation list for surveillance to the sequence data to identify HIV-1 transmitted drug resistance-associated mutations associated with 3 drug classes: NNRTI, NRTI, and protease inhibitors (PI). The total number of HIV-1 nucleotide sequences collected was 18,144 (23.3%) from 77,887 persons newly diagnosed with HIV-1 infection. Transmitted drug resistance mutations was detected in 2