ADVANCED CLINICAL CARE JOB AIDES VERSION1- MARCH 2018

Transcription

1 ADVANCED CLINICAL CARE JOB AIDES VERSION1- MARCH 2018

2 DISCLAIMER The Advanced Clinical Care (ACC), Job Aides was made possible by the support of the American People through the Centres for Disease Control and Prevention (CDC) under the CDC Grant # 5U2GGH As our disclaimer, the contents of this report are the responsibility of Beyond Zero and do not necessarily reflect the views of the CDC or the United States Government. ACKNOWLEDGEMENTS Beyond Zero is thankful to the leadership and staff of Limpopo Department of Health who contributed directly and indirectly to the successful development of the ACC job aides.

3 ASSESSING AND IMPROVING ADHERENCE STEP 1: ASSESS LEVEL OF ADHERENCE Subjective measures Ask, How many tablets have you missed in the last 7 days? Be open and non-judgemental, e.g. everyone misses tablets sometimes Objective measures Pill counts Pharmacy refill data STEP 2: STEP 3: EVALUATE POSSIBLE CAUSES IMPLEMENT INTERVENTIONS Poor tolerance of medication Assess the need for symptomatic treatment with an anti-emetic, antidiarrhoeal agent or fibre supplement. In children, coat mouth with peanut butter if taste is not tolerated Other side effects experienced by patients Reassurance and symptomatic treatment if e.g. dizziness, somnolence, peripheral neuropathy, applicable lipodystrophy Consider single drug switch if neccessary, providing VL is undetectable Substance abuse, non-disclosure or stigma Depression or other mental illness Patient comprehension and dementia Convenience (pill burden, food effect, multiple dosing regimens) Time off work or access to clinic General Points Refer for appropriate counselling or to a support group. A home visit may be helpful to assess home circumstances, where possible Screen and treat for mental illness. Be aware of drug interactions with ART and psychotropic Drugs Establish patient readiness and understanding before starting ART Patient education should include the topics of adherence, the importance of VL suppression and viral resistance, and should preferably take place in the patient s home language Address obvious issues of convenience e.g. pill burden, pill size, frequency of dosing, food or fasting requirements. Simplify where possible Contact employer regarding need for monthly or 2-monthly visits. Consider use of mobile clinic or ART club to improve access to ART The entire healthcare team should reinforce adherence messages, whilst at the same time ensuring non-judgemental attitudes Medication administration should fit into daily schedules Cellphone alarms, treatment diaries or pillboxes may be useful reminders for some patients A treatment partner or the responsible caregiver (in the case of children) can give adherence support as well as directly observe medication ingestio 7

4 CRYPTOCOCCUS ANTIGEN SCREENING (CrAg) ALGORITHM CD4 count <100 cells/mm3 Cryptococcus Antigen test result Cryptococcus reflex test positive Cryptococcus reflex test negative Contact patient for follow-up Screen for symptoms of meningitis 1 Check for special situations 2 Symptomatic Asymptomatic 3 1 Symptomatic for meningitis if either of the following are present: 1.Headache 2.Confusion lumbar lumbar puncture (+) puncture (-) Fluconazole 800mg daily for 2 weeks as outpatient 2 Special situations include: 1. Prior cryptococcal meningitis 2. Pregnant or breastfeeding women 3. Clinical liver disease 3A lumbar puncture may be considered if available Start ART after 4-6 weeks of antifungal therapy Start ART after 2 weeks of antifungal therapy

5 10 STEPS FOR MANAGING PATIENTS ON ART 1. How long on ART? 6. Nutritional status 2. Last viral load and other monitoring? 7. Screen for Ols 3..Side effects and toxicities 8. Dispense ART 4. Drug interactions 9. TCA date 5. Adherence 10. Registers / Tier- system

6 Management of Efavirenz Neurological Adverse Effects Screen for preexis ng psychiatric disorders at baseline Yes No Evaluate and treat symptoms Educate pa ent on common CNS side effects Symptoms remain moderate or severe Ini ate efavirenz therapy Consider use of alterna ve agent or delay treatment un l symptoms improve Monitor for side effects Impaired concentra on Poor school/job performance Sleep disturbances Abnormal dreams Depression Agita on Dizziness Evaluate performance prior to ini a on of efavirenz Adjust administra on me. Take efavirenz during the day. Treat mild to moderate symptoms with psychological support. Assess home and work safety for accident poten al. Unlikely due to efavirenz: refer to job/educa onal assessment Likely due to efavirenz: Monitor and adjust administra on me. Refer severe symptoms to psychiatrist. Discon nue or subs tute efavirenz.

7 Management of Adult Anemia Adverse Reac ons due to Zidovudine Anemia (Usually macrocy c) Correct other causes (e.g. nutrient deficiencies) Hgb Screen for pre-exis ng psychiatric disorders at baseline Reduce AZT to 200 mg every 12 hours Replace AZT with TDF Repeat Hgb in 2 weeks Blood transfusion may be required Repeat Hgb in 1 week

8 Management of ARV- Associated Diarrhea Evaluate pa ent and take 1) Food history 2) Medication history 3) Travel history 4) Note any associated symptoms Diarrhea associated with fever or mucus/blood in stool No Yes Not due to ARVs Possibly due to ARVs Evaluate and treat for infec ous diarrhea Did diarrhea begin within days of star ng ARVs? Administer an mo lity agent if no fever, blood or mucus in stool Evaluate for other causes of diarrhea by stool examina on for WBCs culture and parasite examina on If no improvement, evaluate for other causes of diarrhea Treat based on test results or syndromically for infec ous diarrhea

9 Management of Rash due to Nevirapine or Efavirenz Pa ent on NVP or EFV for <1 month The pa ent have: Systemic symptoms fever, myalgia Mucosal involvement nasal, eye discomfort, blurred vision, and mouth or genital sores Grade 4: Exfolia ve derma s, Steven Johnson syndrome, erythema mul form or moist desquama on Stop all ARVs and other medica on possibly linked to rash. Stop any unnecessary medica on that were started in the last month. Grade skin rash Refer to hospital Grade1 / 2: Diffuse maculopapular rash or dry desquama ons Grade 3: Vesicles/ulcers Treat Grade rash and manage as per grade If Grade 3 rash persists, treat as Grade 4

10 Management of Abacavir Hypersensi vity Reac on Pa ent on NVP or EFV for <1 month Symptoms complex: Mild rash Gastrointes nal symptoms Fa gue, myalgia, arthralgia Cough, shortness of breath and sore throat 2 symptoms from complex Stop ABC immediately Do not rechallenge ABC 0 1 symptoms Con nue ABC with close monitoring

11 ARV DOSE ADJUSTMENT IN RENAL IMPAIRMENT Drug CrCl CrCl ml/min <10 ml/min Tenofovir AVOID Lamivudine 150mg daily 50mg daily Abacavir No change Zidovudine No change 300mg daily Stavudine Didanosine Efavirenz Nevirapine Protease inhibitors >60kg: 200mg daily <60kg: 150mg daily >60kg: 20mg bd <60kg: 15mg bd No change No change >60kg: 100mg daily <60kg: 75mg daily Remember dosage adjustment of ARVs in renal impairment, according to creatinine clearance (CrCl) Don t forget to readjust the dose as renal function improves to avoid under-dosing and suboptimal ART Do not adjust doses if renal impairment is due to an imminently reversible condition e.g: acute dehydration