Antiretroviral therapyand anaesthesia

Abstract

HIV has reached pandemic proportions in Southern Africa. Great emphasis is placed on the prevention and containment of HIV transmission by suppressing virus replication using highly active anti-retroviral therapy (HAART). HAART has proven to be highly effective if taken correctly, and has lead to increased life expectancy. Increasing numbers of HIV-positive patients on antiretroviral (ARV) therapy or HIV-exposed individuals taking prophylaxis present for surgery and critical care management. The anaesthesiologist should be familiar with the anaesthetic implications of HIV as well as the possible drug interactions while on ARV treatment. This article focuses specifically on the anaesthetic implications of the patient on HAART.HAART is HIV treatment with a combination of three or more ARV drugs from five broad classes. The specific HAART regimen in use in South Africa is considered in detail in this article. The pharmacokinetics of the ARV drugs is complex, and subject to interactions at many different sites. Serious drug interactions are possible, including drugs commonly used in anaesthesia. Drug interactions and recommendations are discussed in detail.ARVs are known to cause multiple systemic side effects, including lactic acidosis, Immune Reconstitution Inflammatory Syndrome (IRIS), premature atherosclerosis and increased cardiovascular risk, hyperlipidaemia, insulin resistance, skeletal disorders, hepatotoxicity, lipodystrophy, mitochondrial abnormalities, allergic reactions and pancreatitis.Non-compliance is common, and leads to the rapid development of resistance. The anaesthesiologist may inadvertently exacerbate this in the perioperative period. Recommendations regarding the interruption of treatment and fasting are made. Alternative routes for HAART administration are also explored. The management of the critically ill patient on a HAART regimen is discussed.

Manajemen Anestesi pada Seksio Sesarea Pasien dengan HIV (Human Immunodeficiency Virus)

“…Agen anestesi dapat meningkatkan perubahan farmakodinamik yang berefek pada efikasi dan toksitas obat-obat ARV, dan efek farmakokinetik obat-obat ARV dapat berefek pada absorpsi, distribusi, metabolisme dan eliminasi obat-obat anestesi. 18 Seksio sesarea elektif pada kasus pasien hamil dengan HIV/AIDS merupakan pilihan. untuk mengurangi angka kejadian transmisi HIV dari ibu ke bayi.…”

Tropical Medicine and Anaesthesia; part 2

“…18 Dexamethasone and thiopentone can reduce protease inhibitor concentration. 19 In contrast to the protease inhibitors, nevirapine, a nonnucleoside reverse transcriptase inhibitor used combination antiretroviral therapy, induces cytochrome P450 enzymes. Patients on combination therapy may therefore be taking drugs that both inhibit and induce hepatic enzymes leading to an unpredictable response to co-administered anaesthetic agents.…”

“…Tenofovir, a nucleotide analogue reverse transcriptase inhibitor, does not interact with drugs through the P450 cytochrome system; however, it is associated with a small but significant risk of kidney injury. 19 Nephrotoxic drugs such as gentamycin or non-steroidal anti-inflammatory drugs should consequently be avoided in the perioperative period.…”

HIV and the kidney: what the anaesthesiologist should know

“…6 The protease inhibitors cause accelerated atherosclerosis due to impairment of endothelial function, dyslipidaemia (with increased VLDL and triglycerides and lowered HDL) and insulin resistance and impaired glucose tolerance. 7 • Direct effects of HIV on the kidney (HIV-associated nephropathy, HIV immune complex kidney disease). 3,4,5,6 Apart from the well known risk factors for the development of chronic renal disease in the general population (e.g.…”