Diagnosis kegagalan terapi arv
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Transcript of Diagnosis kegagalan terapi arv
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LAPORANPAGI JUM'AT
- 23 DESEMBER 2016 -
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RESUME KASUS :
2TSMRS
Penderita Tegak B.20CD4 : (?)Terapi :
Duviral dan Efaviren
( selama 1 tahun )
1 TSMRS
Terapi : THEEvaluasi CD4 :Juni : 115Juli : 78
Agustus : 52
OKTOBER 2016
Terapi :AluviaDuviral
HMRS
OS mengeluh lemas memberat, mudah lelah, makan-minum turun, demam, batuk -- ke RSS
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MataCA : (+/+), SI: (-), Oral trush
(+)
KU : lemah,CMTB : 160 Cm. BB : 30 Kg. IMT : 11,72 TD : 120/80. N : 100x/menit. R : 24x/menit. T : 37,5 °C.
AbdomenI : ScaphoidA : Peristaltik (+) NP : TimpaniP : Nyeri tekan epigastrium (-), Hepar/Lien tak teraba
PulmoI : Simetris, KG (-), Retraksi (-)P : Taktil Fremitus Ka=KiP : SonorA : Vesikuler (+/+). RBK (+/-), RBB (-/-). Wheezing (-/-)
CorI : IC tampak di SIC V LMCSP : IC teraba V di SIC V LMCSP : Cardiomegali (-)A : S1-2 reguler, bising (-)
LeherI : JVP 5 ± 2 cmH2OP : Inn ttb
Extremitas :Oedem (-), Akral hangat (+)
Integumentum :Pada dada , perut, punggung, leher : Tampak plak eritem tertutup squama tebal warna putih, multiple tersebar, tungkai bawah kulit kesan erosif
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Sistema integumen : Pada dada , perut, punggung, leher tampak plak eritem tertutup squama tebal warna putih, multiple tersebar, tungkai bawah kulit kesan erosif
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PHQ-GAD
PHQ-2 6
PHQ-922
GAD-25
GAD-713 M (+) I (-) S (-) G (-) E (+) C (+) A
(-) P (+) S (+)
HADS score
Anxiety8
Depresi7
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PEMERIKSAAN PENUNJANGDarah rutin
Hb 5.1AL 3.59AT 334AE 1.33Hmt 14.1Retikulosit 1,38S 77.4L 14.5M 8.1E 0B 0MCV 106MCH 38.3
HatiHbsAg non reaktifGOT 23GPT 11Alb 2.64
GlukosaGDS 121
ElektrolitNa 119K 2.7Cl 92Osm 260
GinjalBUN 5Crea 0.85Urat 2.9
UrinepH 6.5BJ <1.005Prot. -Glu. -Bil. -Uro. -Ket. -Nit. -Erit. 5Leu 7LE -Bact 504.5Yeast 0
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MORFOLOGI DARAH TEPIEritrosit : anisositosis makrosit, makroovalosit, sferosit, sedikit fragmentosit, normokromik, sedikit polikromasi
Leukosit : Jumlah menurun, neutrofilia relatif, granulosit imature (stab) , granulasi toksik, netrofil, vakuolisasi netrofil, sebagian hipersegmentasi netrofil, limfosit atipik, Diffcount manual stab 3%, segmen 82%, limfosit 10%, monosit 5%
Trombosit : jumlah cukup, penyebaran tidak merata clumps +
Kesan :Anemia dengan kelainan morfologi eritrositdan peningkatan respon eritropetikLeukopenia , neutrofilia relatif, reaktivitas neutrofil dan limfosit, sebgaian hipersegmentasi neutrofil
Kesimpulan : Gambaran anemia et causa suspek defisiensi vit B12 disertai proses inflamasi/infeksi bakterial.
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EKG21/12/16 : Sinus Rythm, heart rate 115 kali/menit, normoaxis,
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Ro thorax 21/12/16 :Effusi pleura dextra, pneumonia dextra , besar cor normal
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ASSESMENT• Bisitopenia dengan anemia life threatening ec Susp. Drug induced (AZT)• Health Care Associtaed Pneumonia • B20 stadium III on ARV lini ke-2• Depresi Mayor Mix Generalized Anxiety Disorder• Psoriatic related HIV dengan riwayat psoriatic arthritis• Hyponatremia hypoosmolar euvolemik ec susp SIADH• Hipokalemia• Hipoalbuminemia
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PENDAHULUAN• Human Immunodeficiency Virus/ Acquired
Immunodeficiency Syndrome (HIV/AIDS) -- Masalah kesehatan Global
• UNAIDS (2009) : Indonesia merupakan salah satu negara di Asia dengan perkembangan HIV/AIDS tercepat.
• Pertumbuhan tercepat pasien dengan HIV/AIDS : 7,195 (2006) 76,879 (2011)
• Terapi ARV seumur hidup -- Gagal Terapi dan Problem Resistensi ARV
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PENDAHULUAN• 10% dari pasien dengan viral loads>1000 c/ml,
2/3nya menunjukkan resistensi terhadap salah satu jenis ARV di negara berkembang.
• Prevalensi suppresi HIV pada 6 bulan pertama sebesar 78% setelah pengobatan, 76% setelah 12 bulan pengobatan dan 67% setelah 24 bulan pengobatan.
• Tingkat resistensi HIV DR di Indonesia <5% adalah rendah dibandingkan di Eropa (10% - 20% ) dan USA (17% )
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TERAPI• Diet TKTP (2000 kalori + 100gr
protein)• O2 4 L /mnt nasal kanul• Inf. NaCl 3% 8 tpm • Inj. Ceftazidime 1 gram/8 jam • Inj. Gentamycin 320 mg/24 jam • Transf albumin s/d ≥ 3• Transf PRC s/d Hb ≥10• Aspar K 3x1• Paracetamol 500 mg k/p• Candestatin 4 x 1cc• Metrotexat tunda• ARV tunda• Cognitive Behavioural Therapy
• Monitor KU/VS, BALANCE CAIRAN, UOP 0,5-1 cc/kgBB/jam
• Cek K/S sputum, cat gram• Evaluasi Ro Thoraks 3 hari
paska antibiotik• Evaluasi Elektrolit• Evaluasi Hb paska tranfusi
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MANAJEMEN GAGAL TERAPI DAN
RESISTENSI OBAT ARV PADA PENDERITA HIV
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KRITERIA GAGAL TERAPI1. Gagal Klinis
Dewasa dan remaja: Munculnya infeksi oportunistik baru atau berulang (stadium klinis WHO 4)Kondisi klinis harus dibedakan dengan IRIS yang muncul setelah memulai terapi ARV. Untuk dewasa, beberapa stadium klinis WHO 3 (TB paru atau infeksi bakteri berat lainnya) atau munculnya EPP kembali dapat mengindikasikan gagal terapi.
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2. Gagal VirologisPada ODHA dengan kepatuhan yang baik, viral load di atas 1000 kopi/mL berdasarkan 2x pemeriksaan HIV RNA dengan jarak 3-6 bulan.
3. Gagal ImunologisCD4 turun ke nilai awal atau lebih rendah lagi Atau CD4 persisten dibawah 100 sel/mm3 setelah satu tahun pengobatan atau CD4 turun >50% dari jumlah CD4 tertinggi.
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GAGAL TERAPIODHA harus menggunakan ARV minimal 6 bulan sebelum dinyatakan gagal terapi dalam keadaan kepatuhan yang baik. Kalau ODHA kepatuhan tidak baik atau berhenti minum obat, penilaian kegagalan dilakukan setelah minum obat kembali
secara teratur minimal 3-6 bulan
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Pemantauan terhadap efek samping ARV lini kedua dan substitusi
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Pemantauan terhadap efek samping ARV lini kedua dan substitusi
a
Hipersensitivitas ABC biasanya terjadi dalam 6 minggu pertama dan dapat mengancam jiwa. Segera hentikan obat dan jangan pernahmenggunakan lagi.
Duviral® : AZT+3TC
(Aluvia®) : Lopinavir/ ritonavir (LPV/ r)
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AluviaLopinavir/ ritonavir (LPV/ r)
Efek samping : hiperglikemia (diabetes),
hipercholestrolemi, lipoakumulasi
Intoleransi gastrointestinal, mual, muntah, peningkatan
enzim transaminase
DUVIRALAZT+3TC
Efek Samping :Anemia
Neutropenia beratMiopati
LipoatrofiLipodistrofi
PROBLEM : ANEMIA ( Hb 5.1 mg/dL)
Dosis 30mg tiap 12 jam
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ANEMIA IN HIV INFECTION• Zidovudine (AZT)
therapy is probably the most common cause of anemia in HIV-infected patients.
• The pathophysiology of HIV-associated anemia may involve 3 basic mechanism : decreased RBC production, increased RBC destruction,and ineffective RBC production.
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MANAGEMENT ANEMIA IN HIV INFECTION
• Conduct a general evaluation for anemia. • Review the patient's medications. • When anemia occurs in a patient who has other signs and symptoms suggesting infection or neoplasm (fever, fatigue, weight loss, diarrhea), * evaluate the patient for these conditions.
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REKOMENDASI TES LABORATORIUM SETELAH PEMBERIAN ARV
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APROACHMENT TO ARV DRUG RESISTANCE
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Selection of resistant quasispecies
Incomplete suppression• Inadequate potency• Inadequate drug levels• Inadequate adherence• Pre-existing resistance
Vira
l loa
d
Time
Drug-susceptible quasispeciesDrug-resistant quasispecies
Treatment begins
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3 Categories of HIVDR Relevant to Public HealthAcquired HIVDR (ADR): Occurs when mutations are selected for by ARV drugs in populations receiving ARTSuboptimal drug combinations or adherence, treatment interruptions
Transmitted HIVDR (TDR): Occurs when previously uninfected populations are infected with drug-resistant virus (appropriately measured in recently infected populations)
Pre-Treatment HIVDR (PDR): Detected in individuals starting ART in which HIVDR can be either transmitted or acquired (previous ARVs: treatment, PMTCT, PrEP/PEP etc.)
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DRUGS RESISTANCE TESTING• Genotypic AssaysGenotypic assays detect drug-resistance mutations in relevant viral genes. Most genotypic assays involve sequencing the reverse transcriptase (RT), protease (PR), and integrase (IN) genes to detect mutations that are known to confer drug resistance. • Phenotypic Assays
Phenotypic assays measure the ability of a virus to grow in different concentrations of ARV drugs.
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PANEL REKOMENDASI TERKAIT RESISTENSI OBAT
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PANEL REKOMENDASI TERKAIT RESISTENSI OBAT
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